Low-dose steroid-induced tumor lysis syndrome in a hepatocellular carcinoma patient

Tumor lysis syndrome in premature infant prompting early resection of a large sacrococcygeal teratoma: a case report

BACKGROUND

Sacrococcygeal teratomas (SCTs) are the most common congenital neoplasm and often require resection soon after birth. There are rare reports of cardiac arrest during surgery due to manipulation of the tumor triggering secondary necrosis and hyperkalemia.

CASE PRESENTATION

This case describes a very preterm infant with a SCT who develops spontaneous preoperative tumor lysis syndrome (TLS). The medical team utilized rasburicase and the patient underwent total gross resection at 40 h of life.

CONCLUSIONS

We emphasize the importance of the early recognition and management of tumor lysis syndrome in SCT with rasburicase, aggressive management of hyperkalemia and consideration of early resection of SCTs even in the case of a very premature infant.

Lenvatinib-Induced Tumor Lysis Syndrome in Advanced Hepatocellular Carcinoma

This case report describes a 48-year-old man with hepatocellular carcinoma who developed tumor lysis syndrome (TLS) after 7 days of starting lenvatinib therapy. The patient was hospitalized and received appropriate interventions, including aggressive hydration, allopurinol, rasburicase, and electrolyte management. The patient's condition improved, and he was eventually discharged from the hospital. This case highlights the potential risk of TLS in patients with hepatocellular carcinoma receiving lenvatinib therapy, even after a short duration, and emphasizes the importance of early recognition and management of TLS to prevent serious complications.

Incidence, clinical characteristics and prognosis of tumor lysis syndrome following B-cell maturation antigen-targeted chimeric antigen receptor-T cell therapy in relapsed/refractory multiple myeloma

Background aims

B-cell maturation antigen (BCMA)-targeted chimeric antigen receptor-T cell (CAR-T) therapy is used for refractory or relapsed multiple myeloma (r/r MM). However, CAR-T-related tumor lysis syndrome (TLS) has been observed. We aimed to elucidate the incidence, clinical and laboratory characteristics, and prognosis of CAR-T cell-related TLS.

Methods

Patients (n=105) with r/r MM treated with BCMA-targeted CAR-T cell therapy were included. Patient characteristics, laboratory parameters, and clinical outcomes were assessed.

Results

Eighteen (17.1%) patients developed TLS after BCMA-targeted CAR-T cell therapy. The median time till TLS onset was 8 days. Patients with TLS had steep rise in uric acid (UA), creatinine, and lactate dehydrogenase (LDH) within 6 days following CAR-T cell infusion and presented earlier and persistent escalation of cytokines (C-reactive protein [CRP], interleukin-6 [IL-6], interferon-γ [IFN-γ], and ferritin levels). All 18 patients had cytokine release syndrome (CRS), of which 13 (72.2%) developed grade 3-4 CRS. Three of 18 patients (16.7%) developed immune effector cell-associated neurotoxicity syndrome (ICANS): two patients with grade 1 ICANS and one with grade 2 ICANS. TLS development had a negative effect on the objective response rate (77.8% in the TLS group vs. 95.4% in the non-TLS group, p<0.01). During the median follow-up of 15.1 months, the median PFS was poorer of patients with TLS (median: 3.4 months in the TLS group vs. 14.7 months in the non-TLS group, p<0.001, hazard ratio [HR]=3.5 [95% confidence interval [CI] 1.5-8.5]). Also, TLS development exhibited significant effects on OS (median: 5.0 months in the TLS group vs. 39.8 months in the non-TLS group, p<0.001, hazard ratio [HR]=3.7 [95% CI 1.3-10.3]). TLS was associated with a higher tumor burden, elevated baseline creatinine and UA levels, severe CRS, pronounced CAR-T cell expansion, and corticosteroid use.

Conclusion

TLS is a frequently observed CAR-T therapy complication and negatively influences clinical response and prognosis. Close monitoring for TLS should be implemented during CAR-T cell therapy, especially for those at high TLS risk.

Tumor Lysis Syndrome Following Thoracotomy Under Cardiopulmonary Bypass in a Case of Hepatocellular Carcinoma With Right Atrial and Inferior Vena Cava Tumor Thrombus

Tumor lysis syndrome (TLS) occurring after surgical resection of right atrium (RA) and inferior vena cava (IVC) tumor thrombus is a very rare but insidious condition. We report a case of hepatocellular carcinoma who developed TLS after uneventful excision of RA+IVC tumor thrombus under median sternotomy and cardiopulmonary bypass (CPB). Although the procedure was not expected to arouse massive tumor cell necrosis, post-operative course was complicated by metabolic acidosis, hypocalcemia, and progressive hyperkalemia indicative of TLS. Unfortunately, laboratory diagnosis of TLS was delayed under conditions of continuous renal replacement therapy (CRRT) for peri-operative acute renal failure. Despite all efforts, the patient died 36 hours after surgery due to lethal arrhythmia and disseminated infarction of the kidneys, spleen, and liver.

Tumor Lysis Syndrome in Patients With Hepatocellular Carcinoma: A Systematic Review of Published Case Reports

Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency. It is characterized by massive tumor cell death leading to metabolic derangements and multiple organ failure. It is a rare complication of hepatocellular carcinoma (HCC) with only a few cases have been reported in the literature to date.

We collected and summarized published case reports of tumor lysis syndrome in patients with HCC. We also reported one additional case who developed TLS after sorafenib therapy and wrote a clinical vignette. A comprehensive and current search for relevant articles was conducted in Medline and EMbase through May 2018. A systematic review was performed following the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 

A total of 28 cases of TLS associated with HCC were enrolled in our review. The median age of included cases was 55.5 years with a male to female ratio of 25:3. The two most common attributed factors of TLS were transcatheter arterial chemoembolization (TACE) (12 cases, 42.9 %) and sorafenib (nine cases, 32.1%). Among enrolled cases, the diameter of the largest tumor was 12 cm. Regarding Barcelona Clinic Liver Cancer (BCLC) staging, seven cases were at least stage A (22.6%), 11 cases were at least stage B (35.5%), and 10 cases were at least stage C (32.3%). The median time of onset of TLS was three days. As for uric acid-lowering agents, nine cases (32.1%) used allopurinol and four cases (14.3%) used rasburicase. Ten cases (35.7%) did not specify the medication prescribed. The overall mortality rate of this cohort was 67.9%.

Compared with patients developing TLS following TACE, patients who had TLS following sorafenib therapy had a later onset of TLS (two days versus seven days, p < 0.001) and a more advanced stage of HCC (p = 0.002). There was a trend toward increased mortality of patients in the sorafenib group in comparison with those in the TACE group (77.8% versus 41.7%, p = 0.18).

The results of this current review suggest that TLS rarely occurs in HCC but carries significantly higher mortality compared to TLS occurring in hematologic malignancies. It may occur shortly after TACE or with a delayed onset following sorafenib therapy. Considering the kaleidoscope of novel therapies and diverse pathogenesis of HCC, it is crucial for clinicians to recognize the clinicolaboratory derangements suggestive of TLS and initiate appropriate management. The present review highlights the need for clinicians to consider TLS within differentials when caring for patients with HCC.

Steroid-induced Lactic Acidosis in Diffuse Large B-cell Lymphoma

A previously healthy 53-year-old male with primary membranous nephropathy (positive anti phospholipase A2 antibody) presented to our hospital with worsening cough, shortness of breath, hypotension, and malaise. During his hospital stay, he quickly progressed to overt respiratory failure requiring mechanical ventilation. Upon further workup, he met clinical criteria for tumor lysis syndrome due to an unknown diffuse large B-cell lymphoma, who underwent rapid cytolysis after starting stress dose steroids.

Update on the prevention and treatment of tumor lysis syndrome

Tumor lysis syndrome is a constellation of metabolic derangements seen when tumor cells die and release their intracellular contents into the systemic circulation. Hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia may lead to severe organ dysfunction and even death. Tumor lysis syndrome is classically considered a complication of successful cancer treatment, but it can also occur in untreated malignancies characterized by rapid proliferation. In this review, we cover the types of cancers and chemo- and immunotherapies associated with tumor lysis syndrome, the mechanisms by which severe metabolic derangements can develop, and the available treatments.

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.

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.

Tumor Lysis-like Syndrome in Eosinophilic Disease of the Lung: A Case Report and Review of the Literature

Tumor lysis syndrome (TLS) is a metabolic disorder that is generally associated with a malignancy leading to hyperuricemia, hyperphosphatemia, and acute kidney injury. On the other hand, we sometimes encounter these phenomena in nonmalignant disease, which has been referred to as tumor lysis-like syndrome in some studies. We herein experienced a case in which tumor lysis-like syndrome occurred in the course of therapy for eosinophilic disease of the lung, a nonmalignant disease. Even in nonmalignant disease, massive cell lysis induced by therapy can cause phenomena such as TLS or tumor lysis-like syndrome.