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

Spontaneous tumor lysis syndrome in patients with solid tumors: a scoping review of the literature

No systematic synthesis of all cases of spontaneous tumor lysis syndrome (STLS) in adult patients with solid tumors is available to date. Herein, we aim to recognize specific STLS characteristics and parameters related to a worse prognosis. We conducted a systematic search for randomized controlled trials, cohorts, case-control studies, and case reports. The primary endpoints were death and the need for renal replacement therapy (RRT) due to STLS. We estimated crude odds ratios (ORs) with 95% confidence intervals (95%CI) via univariate binary logistic regression. We included one cohort of 9 patients and 66 case reports of 71 patients [lung cancer 15(21.1%)]. Regarding the case reports, most patients [61(87.1%)] had metastatic disease [liver 46(75.4%)], developed acute kidney injury [59(83.1%)], needed RRT [25(37.3%)], and died due to STLS [36(55.4%)]. Metastatic disease, especially in the liver [p = 0.035; OR (95%CI): 9.88 (1.09, 89.29)] or lungs [p = 0.024; 14.00 (1.37, 142.89)], was significantly associated with STLS-related death compared to no metastasis. Cases resulting in death had a significantly higher probability of receiving rasburicase monotherapy than receiving no urate-lowering agents [p = 0.034; 5.33 (1.09, 26.61)], or the allopurinol-rasburicase combination [p = 0.023; 7.47 (1.40, 39.84)]. Patients receiving allopurinol were less likely to need RRT compared to those not receiving it or those receiving rasburicase. In conclusion, current anecdotal evidence demonstrated that metastatic disease, especially in the liver and lungs, may be associated with STLS-related death compared to no metastatic status. Careful surveillance of high-risk cases within larger studies is essential to identify markers predicting morbidity or mortality.

Association of Tumor Lysis Syndrome and Metastatic Melanoma

Background

Tumor lysis syndrome (TLS) is a known oncologic emergency characterized by severe metabolic derangements. TLS has been well documented in patients with hematologic malignancies, but rarely with metastatic melanoma. The objective of this study was to investigate the clinical characteristics and outcomes of TLS with metastatic melanoma. 

Methods

Retrospective literature review and analysis.

Results

Eighteen cases of TLS were identified with metastatic melanoma from published literature. The median age of patients was 63 years (36-79 years). All patients have stage IV disease. Seven cases (39%) of TLS were associated with multiple treatment regimes, including nivolumab (22%), ipilimumab (16%), and dacarbazine (22%). The time from treatment to diagnosis was 3.5 days (8 hours-21 days) in treatment-related TLS. Three cases (17%) were due to spontaneous TLS. The majority of cases have a high tumor burden (77.5%) and liver metastasis (83%). Seven cases were treated with rasburicase (39%). The mortality rate was 100% for the patients with spontaneous TLS and 73% for patients with treatment-related TLS. Three cases utilized traditional chemotherapy and the six most recent cases of treatment-associated TLS utilized immunotherapy and targeted therapy.

Conclusion

TLS in metastatic melanoma, due to either spontaneous or treatment-related causes, is associated with a very high mortality rate. This study highlights the importance of awareness, early intervention, and risk assessment of this underdiagnosed emergency.

Tumor lysis syndrome in a patient with metastatic melanoma treated with nivolumab

A 79-year-old man with metastatic melanoma of the right maxillary sinus and multiple liver metastases received a single dose of nivolumab. Eight days later, he experienced impaired consciousness, accompanied by abnormal laboratory and electrocardiographic findings. He was therefore diagnosed with tumor lysis syndrome (TLS). Laboratory and electrocardiographic findings improved immediately after continuous hemodiafiltration; however, he died 22 days after receiving nivolumab. Autopsy revealed massive tumor necrosis in the liver. There are few case reports of TLS associated with immune checkpoint inhibitors, indicating that we should be prepared to manage especially in a patient with liver involvement of high tumor burden.

Current understanding of tumor lysis syndrome

Tumor lysis syndrome (TLS) is an oncologic emergency from the intracellular release of material in lysing malignant cells. The earlier it is treated, the less likely it is to be harmful to an individual and spread through the body. Common complications of TLS include arrhythmias, which are caused by hypocalcemia or hyperkalemia, renal failures due to hyperuricemia or hyperphosphatemia, and seizures. Furthermore, the risk to develop TLS varies widely based on several factors including factors that are related to disease, the patient, and the treatment of the patient. Laboratory data can be used to gauge the severity of TLS based on patient serum levels for specific markers. On the contrary, evidence of TLS via radiological imaging and electrocardiogram findings has been a limited way to evaluate TLS, indicating the need for further research in this area. Common trends of treatment have also been seen in the past several years, evident by case studies seen in the following literature review.

Tumor lysis syndrome and metastatic melanoma

Tumor lysis syndrome (TLS) is a potential emergent complication of oncologic treatment. TLS is commonly reported in hematological malignancies with rapid cell turnover rates, but is relatively rare in solid tumors. TLS is most frequently a result of cancer treatment in combination with a large tumor burden, but has occasionally been reported to occur spontaneously, especially in cases of advanced or metastatic disease. In this article, we describe the case of a patient with newly diagnosed metastatic melanoma that developed TLS two days after initiation of corticosteroids. In addition, we present a brief literature review of melanoma-associated TLS and review the etiology, diagnosis, and management of TLS.

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.

Tumor Lysis Syndrome in Solid Tumors: An up to Date Review of the Literature

Tumor lysis syndrome (TLS) is a potentially deadly complication of tumors or their treatment. This syndrome consists of a constellation of laboratory findings such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia, known as laboratory TLS. When clinical complications such as seizures, acute renal failure, and cardiac dysrhythmias occur in patients with laboratory TLS, the syndrome is called clinical TLS. TLS is especially common in patients with hematological malignancies with rapid cellular turnover rates such as acute lymphocytic leukemia and Burkitt lymphoma, but is very rare in patients with solid tumors. Nevertheless, there are multiple reports in the literature on the occurrence of TLS in patients with solid tumors. In this review article, we summarize the current data on the occurrence of TLS in patients with solid tumors. We propose an algorithm of risk stratification and prevention of TLS in patients with solid cancers.

Tumor lysis syndrome and malignant melanoma

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.

Tumor lysis syndrome following trastuzumab for breast cancer: a case report and review of the literature

Tumor lysis syndrome, a complication of anticancer chemotherapy, results from rapid lysis of malignant cells. We report tumor lysis syndrome in a patient treated with trastuzumab for metastatic breast carcinoma. A 69-year-old woman was diagnosed with multiple liver metastases 1 month after mastectomy. As her liver functions had deteriorated, chemotherapeutic agents were contraindicated and she was treated with trastuzumab alone. On day 6 of the first course of trastuzumab, she developed tumor lysis syndrome. As her liver functions showed deterioration due to multiple hepatic metastases, hemodialysis was contraindicated. Acute renal failure worsened and she died 11 days after the administration of trastuzumab.

Recognizing and managing the expanded risk of tumor lysis syndrome in hematologic and solid malignancies

Tumor lysis syndrome (TLS) is widely recognized as a serious adverse event associated with the cytotoxic therapies primarily used in hematologic cancers, such as Burkitt lymphoma and acute lymphoblastic leukemia. In recent years, TLS has been more widely observed, due at least in part to the availability of more effective cancer treatments. Moreover, TLS is seen with greater frequency in solid tumors, and particularly in bulky tumors with extensive metastases and tumors with organ or bone marrow involvement. The consequences of TLS include the serious morbidity and high risk of mortality associated with the condition itself. Additionally, TLS may delay or force an alteration in the patient’s chemotherapy regimen. The changing patterns of TLS, as well as its frequency, in the clinical setting, result in unnecessarily high rates of illness and/or fatality. Prophylactic measures are widely available for patients at risk of TLS, and are considered highly effective. The present article discusses the various manifestations of TLS, its risk factors and management options to prevent TLS from occurring.

An unusual presentation of tumor lysis syndrome in a patient with advanced gastric adenocarcinoma: case report and literature review

Tumor lysis syndrome (TLS) is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, and secondary hypocalcemia in patients with a malignancy. When these laboratory abnormalities develop rapidly, clinical complications such as cardiac arrhythmias, acute renal failure, seizures, or death may occur. TLS is caused by rapid release of intracellular contents by dying tumor cells, a condition that is expected to be common in hematologic malignancies. However, TLS rarely occurs with solid tumors, and here we present the second chemotherapy-induced TLS in a patient with advanced gastric adenocarcinoma to be reported in the literature. We also provide information regarding the total cases of TLS in solid tumors reported from 1977 to present day. Our methodology involved identifying key articles from existing reviews of the literature and then using search terms from these citations in MEDLINE to find additional publications. We relied on a literature review published in 2003 by Baeksgaard et al., where they gathered all total 45 cases reported from 1977 to 2003. Then, we looked for new reported cases from 2004 to present day. All reports (case reports, brief reports, letters to editor, correspondence, reviews, journals, and short communications) identified through these searches were reviewed and included.

Spontaneous Tumor Lysis Syndrome in Metastatic Melanoma

Tumor lysis syndrome (TLS) complicating non-hematologic malignancy is infrequent and spontaneous TLS is a very rare occurrence in patients with solid tumors. We report a case of spontaneous TLS in a patient with metastatic melanoma. Clinicians should have awareness of the possibility of spontaneous TLS in patients with solid tumors and should recognize the clinical presentation and laboratory tests for its diagnosis.

Tumor lysis syndrome after transcatheter arterial infusion of cisplatin and embolization therapy for liver metastases of melanoma

BACKGROUND

Tumor lysis syndrome (TLS) is rare in the treatment of solid tumors, but it may occur in myelolymphoproliferative diseases.

METHODS

A 58-year-old man with bulky metastatic melanoma of the liver was treated with transcatheter arterial infusion of cisplatin and embolization therapy. The patient developed classic signs of TLS within 24 h of chemotherapy, including acute renal failure.

RESULTS

The patient was treated with aggressive hydration, allopurinol, and repeated hemodialysis. He gradually improved and his biochemical markers returned to normal.

CONCLUSION

TLS is an uncommon, but potentially life-threatening, complication in melanoma and other solid tumors. It is important for oncologists to recognize this complication and prevent its development if bulky metastatic disease and several pre-existing risk factors, such as multiple and bulky liver metastases, elevated lactate dehydrogenase, and hyperuricemia, are present.

Systematic review of the clinical effect of glucocorticoids on nonhematologic malignancy

BACKGROUND

Glucocorticoids are often used in the treatment of nonhematologic malignancy. This review summarizes the clinical evidence of the effect of glucocorticoid therapy on nonhematologic malignancy.

METHODS

A systematic review of clinical studies of glucocorticoid therapy in patients with nonhematologic malignancy was undertaken. Only studies having endpoints of tumor response or tumor control or survival were included. PubMed, EMBASE, the Cochrane Register/Databases, conference proceedings (ASCO, AACR, ASTRO/ASTR, ESMO, ECCO) and other resources were used. Data was extracted using a standard form. There was quality assessment of each study. There was a narrative synthesis of information, with presentation of results in tables. Where appropriate, meta-analyses were performed using data from published reports and a fixed effect model.

RESULTS

Fifty four randomized controlled trials (RCTs), one meta-analysis, four phase l/ll trials and four case series met the eligibility criteria. Clinical trials of glucocorticoid monotherapy in breast and prostate cancer showed modest response rates. In advanced breast cancer meta-analyses, the addition of glucocorticoids to either chemotherapy or other endocrine therapy resulted in increased response rate, but not increased survival. In GI cancer, there was one RCT each of glucocorticoids vs. supportive care and chemotherapy +/- glucocorticoids; glucocorticoid effect was neutral. The only RCT found of chemotherapy +/- glucocorticoids, in which the glucocorticoid arm did worse, was in lung cancer. In glucocorticoid monotherapy, meta-analysis found that continuous high dose glucocorticoids had a detrimental effect on survival. The only other evidence, for a detrimental effect of glucocorticoid monotherapy, was in one of the two trials in lung cancer.

CONCLUSION

Glucocorticoid monotherapy has some benefit in breast and prostate cancer. In advanced breast cancer, the addition of glucocorticoids to other therapy does not change the long term outcome. In GI cancer, glucocorticoids most likely have a neutral effect. High dose continuous glucocorticoids have a detrimental effect in nonhematologic malignancy. Glucocorticoid therapy might have a deleterious impact in lung cancer.

Tumour Lysis Syndrome in Solid Tumours

Tumour lysis syndrome (TLS) is an oncological emergency that results from massive cytolysis of malignant cells with a sudden release of their cellular contents, such as intracellular ions and metabolic by-products, into the systemic circulation. This syndrome is common in tumours with rapid cell turnover and growth rates, and in bulky tumours with high sensitivity to antineoplastic treatments. It is, therefore, a well-recognised clinical problem in haematological malignancies. It is rarely observed in solid tumours. Here, published studies are reviewed, beginning with the first report of TLS in solid tumours. Reported solid TLS cases are evaluated according to their common features and differences, and their similarities with those seen in haematological malignancies. Basic principles for the prevention and management of TLS are mentioned, with particular emphasis on solid tumours.

Complete Heart Block and Cardiac Tamponade Secondary to Merkel Cell Carcinoma Cardiac Metastases

This is a unique case of Merkel cell carcinoma, a rare neuroendocrine tumor, metastasizing to the heart and inducing a progression of cardiac complications such as new-onset atrial fibrillation, malignant pericardial effusion with tamponade physiology, first-degree heart block, and complete heart block. Metastases to the heart are relatively rare but should be suspected if a patient with a known neoplasm presents with new cardiac manifestations. This is the first case report of cardiac metastases from Merkel cell carcinoma causing cardiac tamponade or complete heart block. This case highlights the clinical decision-making involved in managing cardiac tamponade and complete heart block in the setting of metastatic disease to the heart.

Acute hepatic failure and multi-system organ failure secondary to replacement of the liver with metastatic melanoma

Background

Metastatic malignant melanoma to the liver resulting in fulminant hepatic failure is a rare occurrence.

Case presentation

A 46 year old man presented to hospital with massive hepatomegaly, elevated liver enzymes and increased lactate three weeks following resection of a malignant melanoma from his shoulder (Clark level 5). Initially stable, he decompensated 24 to 48 hours subsequent to presentation with respiratory failure requiring mechanical ventilation, distributive shock requiring high dose vasopressor infusion, coagulopathy refractory to plasma infusion, progressive rise in liver enzymes and severe metabolic abnormalities including hyperkalemia, acidosis, hyperphosphatemia, hyperuricemia and hypocalcemia. Refractory to aggressive physiologic support he received palliation. Autopsy revealed >80% liver infiltration by metastatic malignant melanoma.

Conclusion

We report a case of fulminant hepatic failure secondary to metastatic malignant melanoma infiltration of the liver.

Pathophysiology, clinical consequences, and treatment of tumor lysis syndrome

Tumor lysis syndrome is an oncologic emergency that is characterized by severe electrolyte abnormalities and, frequently, by acute renal failure. The syndrome typically occurs in patients with lymphoproliferative malignancies, most often after initiation of treatment. The pathophysiology involves massive tumor cell lysis resulting in the release of large amounts of potassium, phosphate, and uric acid. Deposition of uric acid and calcium phosphate crystals in the renal tubules may lead to acute renal failure, which is often exacerbated by concomitant intravascular volume depletion. The kidney normally excretes these products, and consequently preexisting renal failure exacerbates the metabolic derangements of tumor lysis syndrome. Standard treatment aims to clear high plasma levels of potassium, uric acid, and phosphorus; correct acidosis; and prevent acute renal failure by way of aggressive intravenous hydration; lowering serum potassium levels; use of allopurinol; urinary alkalinization; or renal replacement therapy (if necessary). Allopurinol is the standard of care for treating hyperuricemia of malignancy, but is associated with drawbacks. Recombinant urate oxidase (rasburicase), which recently became available in the United States, provides a safe and effective alternative to allopurinol for lowering uric acid levels and preventing uric acid nephropathy.

Acute tumor lysis syndrome in solid tumors--a case report and review of the literature

PURPOSE

Tumor lysis syndrome (TLS) is a potential complication in cancer therapy. It may occur in highly sensitive tumors, especially in childhood cancers and acute leukemias, whereas it is rare in the treatment of adult solid tumors. TLS is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia following massive lysis of malignant cells. Complications include acute renal failure and metabolic acidosis. We report the first case of TLS during chemotherapy in a patient with metastatic medulloblastoma, together with a review of the literature regarding the occurrence of TLS in patients with solid tumors.

METHODS

Data regarding clinical and biochemical parameters were extracted from the actual patients' files. Reports of TLS in the English language literature up to 2002 were identified by searching Medline.

RESULTS

A 23-year old male with metastatic medulloblastoma received chemotherapy with cisplatin and etoposide due to massive extracerebral manifestations including metastases to the liver, mediastinal lymph nodes and bone marrow metastases. The patient developed classical signs of TLS on the second day of chemotherapy, including acute renal failure. A 17-fold increase in plasma LDH up to 87608 U/l was observed together with a 4-fold increase in plasma creatinine. The patient was treated with aggressive hydration, allopurinol and repeated hemodialysis. During the following days the patient improved and the biochemical markers all returned to normal. REVIEW. Reviewing the literature, a total of 45 patients with solid tumors who developed TLS have been reported. Most of the patients presented with metastatic, therapy-sensitive disease. Although preventable in practically 100% of patients, TLS is a potentially fatal complication, and in this material the mortality rate was one in three. Risk factors included increased LDH, hyperuricemia and pretreatment azotemia.

CONCLUSIONS

TLS is only rarely associated with treatment of solid tumors. Precautions should be taken to avoid this potentially fatal complication in (chemo)therapy of solid tumors, especially in therapy-sensitive tumors presenting with bulky, metastatic disease and preexisting risk factors, including azotemia, elevated LDH and hyperuricemia. Prophylactic treatment to avoid TLS includes allopurinol, hydration prior to treatment and alkalization of the urine. Urate oxidase (rasburicase) is now beginning to replace allopurinol as a more effective way of reducing hyperuricemia and thereby the risk of TLS.