Tumour lysis syndrome: an unexpected adverse event associated with ipilimumab

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.

Immune Checkpoint Inhibitor-Associated Tumor Lysis Syndrome: A Real-World Pharmacovigilance Study

Introduction: Immune checkpoint inhibitors (ICIs) have substantially improved the clinical outcomes of various malignancies. However, the adverse event of tumor lysis syndrome (TLS) has not been included in the National Comprehensive Cancer Network guidelines or drug inserts. In this study, we aimed to establish the relationship between ICI therapies and TLS events using data from a real-world pharmacovigilance database.

Methods: The MedDRA terms of TLS and both generic and brand names of ICIs were retrieved from the FDA Adverse Event Reporting System. Four frequentist algorithms were employed to confirm the association between the TLS and the ICI regimens, involving anti-cytotoxic T lymphocyte antigen-4 (anti-CTLA-4), anti–programmed death receptor-1 (PD-1)/programmed cell death 1 ligand 1 (PD-L1), and anti-(CTLA-4 + PD-1). A descriptive and statistical analysis was performed according to the case information.

Results: One hundred sixty-four TLS cases, where patients underwent anti-CTLA-4 (n = 14), anti-(PD-1)/(PD-L1) (n = 113), or anti-(CTLA-4 + PD-1) (n = 37) therapies, were collected between the first quarter of 2004 and the fourth quarter of 2020. The most coverage-reporting year, age-group, sex, reporter, region, country, and indication were 2020 (n = 62), 60–74 years (n = 65), males (n = 105), physician (n = 66), Asia (n = 80), Japan (n = 67), and lung and thymus malignancies (n = 40), respectively. The median TLS onset time associated with anti-CTLA-4, anti-(PD-1)/(PD-L1), and anti-(CTLA-4 + PD-1) therapies was 6 (IQR: 2–39.5), 9 (IQR: 2–40), and 20 (IQR: 7.5–37.75) days, respectively. Mortality distribution of 71 reported death outcomes among three groups was statistically significant. All four algorithm signal values of anti-(CTLA-4 + PD-1) were higher than those of anti-CTLA-4 and anti-(PD-1)/(PD-L1).

Conclusion: Elderly male patients with lung and thymus malignancies are frequently predisposed to TLS. ICI therapies could induce TLS in both solid and hematological malignancies. The rapid onset time and poor outcomes of patients prompt caution from health-care professionals.

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.

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

Acute Angle Closure Precipitated by Hemorrhage and Necrosis of a Large Uveal Melanoma in the Setting of Systemic Immunomodulatory Therapy

Management of nonmetastatic uveal melanoma has been well studied and a large body of work has been published by the Collaborative Ocular Melanoma Study (amongst many others). Management of uveal melanoma that is found to be metastatic upon initial diagnosis, however, is less well defined. We report an interesting case of acute angle closure caused by necrosis and hemorrhage into a large uveal melanoma occurring shortly after initiation of immunomodulatory therapy with ipilimumab and nivolumab for metastatic disease. The use of these immunomodulatory agents in the setting of metastatic uveal melanoma is not well studied, and our case illustrates the importance of interdisciplinary communication in order to best decide the timing of surgical and systemic medical management to optimize outcomes and minimize morbidity.