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

Tumour lysis syndrome in a neonate with transient abnormal myelopoiesis

BACKGROUND

Tumor lysis syndrome (TLS) is an oncological emergency associated with hematological malignancies or highly proliferative solid tumors, commonly after chemotherapy. It is rarely associated with transient abnormal myelopoiesis.

OBSERVATION

We report a rare case of a neonate with transient abnormal myelopoiesis and tumor lysis syndrome, complicated with concomitant heart failure due to an underlying atrioventricular septal defect. Hyperhydration was contraindicated due to heart failure. The patient was managed conservatively with full recovery.

CONCLUSION

Tumor lysis syndrome should be suspected in neonates with transient abnormal myelopoiesis with electrolyte abnormalities. Treatment options should be considered carefully for their risks and benefits.

Afatinib-Induced Tumor Lysis Syndrome in Pulmonary Adenocarcinoma: A Case Report and Literature Review

Tumor lysis syndrome (TLS) is a potentially fatal oncological emergency that typically develops during the treatment of rapidly proliferating malignancies. It is infrequently reported in solid tumors, such as pulmonary adenocarcinoma. A 59-year-old male patient with shortness of breath presented with a 3.3 cm × 3.0 cm mass in the right upper lobe, along with massive right-sided pleural effusion. A percutaneous needle biopsy was performed, and a diagnosis of pulmonary adenocarcinoma with an epidermal growth factor receptor (EGFR) mutation was made. The patient was treated with afatinib because of the malignant pleural effusion and multiple metastases to the intrathoracic lymph nodes, left scapula, and brain. After 4 days of afatinib treatment, he developed oliguric acute kidney injury and progressively worsening dyspnea. Based on the clinical and laboratory findings, the patient was diagnosed with afatinib-induced TLS. To the best of our knowledge, this is the first reported case of afatinib-induced TLS in pulmonary adenocarcinoma.

Predicting survival for patients with mesothelioma: development of the PLACE prognostic model

INTRODUCTION

The overall survival of patients with mesothelioma is poor and heterogeneous. At present, the prediction model for Chinese patients needs to be improved. We sought to investigate predictors of survival in malignant pleural mesothelioma and develop prognostic prediction models.

METHODS

This Two-center retrospective cohort study recruited patients with pathologically diagnosed mesothelioma at Beijing Chao-Yang Hospital and Beijing Tong-Ren Hospital. We developed a new prognostic prediction model based on COX multivariable analysis using data from patients who were recruited from June 1, 2010 to July 1, 2021 in Beijing Chao-Yang Hospital (n = 95, development cohort) and validated this model using data from patients recruited from July 18, 2014 to May 9, 2022 in Beijing Tong-Ren Hospital (n = 23, validation cohort). Receiver operating characteristic analysis was used to estimate model accuracy.

RESULTS

The parameters in this new model included PLT > 289.5(10^9/L) (1 point), Lymphocyte > 1.785(10^9/L) (-1point), Age > 73 years old (1 point), Calcium > 2.145(mmol/L) (-1point), Eastern Cooperative Oncology Group performance status (ECOG PS) > 2 (2 points). When the sum of scores < 0, it is recognized as a low-risk group; when the score is 0 ~ 3, it is recognized as a high-risk group. The survival rate of patients in the high-risk group was significantly lower than that in the low-risk group (hazard ratio [HR], 3.878; 95% confidence interval [CI], 2.226-6.755; P < 0.001). The validation group had similar results (HR,3.574; 95%CI,1.064-12.001; P = 0.039). Furthermore, the areas under the curve 6 months after diagnosis in the two cohorts were 0.900 (95% CI: 0.839-0.962) and 0.761 (95% CI: 0.568-0.954) for development and validation cohorts, respectively.

CONCLUSION

We developed a simple, clinically relevant prognostic prediction model for PLACE by evaluating five variables routinely tested at the time of diagnosis. The predictive model can differentiate patients of Chinese ethnicity into different risk groups and further guide prognosis.

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.

Post-operative Tumor Lysis Syndrome in High-Grade Uterine Sarcoma

Tumor lysis syndrome (TLS) is a well-known oncologic emergency. It is a constellation of metabolic derangements usually observed in hematological malignancies due to rapid cell lysis, typically due to chemotherapy or radiotherapy initiation. Spontaneous TLS is an unusual complication in solid malignancies, and only a few cases have previously been reported for spontaneous TLS in gynecological malignancies. We report a case of TLS in a 50-year-old female patient shortly after resection of high-grade uterine sarcoma. We review previous TLS cases in uterine malignancies and the associated morbidity and mortality.

A Rare Syndrome in a Rare Carcinoma: A Case of Spontaneous Tumor Lysis Syndrome in Small-Cell Liver Carcinoma

Spontaneous tumor lysis syndrome (STLS) is a rare, oncologic emergency, consisting of life-threatening acute renal failure, hyperuricemia, hyperkalemia, and hyperphosphatemia, prior to the initiation of cytotoxic therapy. Here, we describe a case of STLS in a patient with newly diagnosed small-cell liver carcinoma (SCLC). A 64-year-old female with no significant past medical history presented with a one-month history of jaundice, pruritus, pale stools, dark urine, and right upper quadrant pain. CT of the abdomen revealed a heterogeneous-enhancing intrahepatic mass. CT-guided biopsy of the mass revealed SCLC. At follow-up, labs were significant for potassium 6.4 mmol/L, phosphorus 9.4 mg/dL, uric acid 21.4 mg/dL, calcium 9.0 mg/dL, and creatinine 6.9 mg/dL. She was admitted and treated with aggressive fluid rehydration and rasburicase, with eventual improvement in renal function and normalization of electrolytes and uric acid levels. On the rare occasion that STLS occurs in solid tumors, lung, colorectal, and melanoma are most common, with liver metastases occurring in 65% of cases. Our patient's SCLC was a primary liver malignancy with a large tumor burden, both of which may have predisposed her to develop STLS. Rasburicase is the first line in the treatment of acute tumor lysis syndrome as it quickly decreases uric acid. Identifying SCLC as a risk factor for STLS is key. Due to the high morbidity and mortality associated with this rare phenomenon, a prompt diagnosis is required.

Tumor Lysis Syndrome: A Rare Complication of Metastatic Gastric Cancer and a Possible Indicator of Disease Progression

Tumor lysis syndrome (TLS) is an oncologic emergency that is usually associated with hematologic malignancies either spontaneously or following early chemotherapy and is caused by massive tumor cell lysis. However, it has been rarely reported in solid tumors. We report a case of 25-year-old lady recently diagnosed with metastatic gastric adenocarcinoma who developed TLS after the fourth cycle of chemoimmunotherapy (FOLFOX plus Nivolumab). She presented with abdominal pain, decrease in oral intake and decreased urine output. Laboratory studies showed acute kidney injury with electrolyte disturbances and was diagnosed initially with autoimmune nephritis secondary to Nivolumab but was later found to have TLS and recovered after appropriate treatment. Soon after this complication, our patient was found to have disease progression on imaging which makes the incidence of TLS an indicator of disease progression.

Cell-Membrane-Anchored DNA Logic-Gated Nanoassemblies for In Situ Extracellular Bioimaging

Extracellular K⁺ and adenosine triphosphate (ATP) levels are significantly elevated in the tumor microenvironment (TME) and can be used as biomarkers for early cancer detection and tumor localization. Most reported TME sensors only respond to single abnormal factors, resulting in a lack of accuracy and specificity for the detection of complex environments. Thus, precisely locating the TME remains challenging. In this work, we aimed to develop an intelligent DNA nanoassembly controlled by a "YES-AND" logic circuit using a bimolecular G-quadruplex (G4) and ATP aptamer as logical control units. As a proof of concept, in the presence of K⁺ (input 1) and ATP (input 2), the YES-AND Boolean operator returned a true value and the output was the fluorescence resonance energy transfer (FRET) signal, indicating high sensitivity and selectivity. After being anchored to living cell surfaces, this logic nanosensor imaged extracellular K⁺ and ATP present at abnormal levels in situ. Owing to diverse disease markers in the TME, this novel logic sensor might hold great promise for the targeted delivery of intelligent anticancer drugs and Boolean logic-controlled treatment.

Potassium in Solid Cancers

Electrolyte disorders are a frequent finding in cancer patients. In the majority of cases the etiologies of such disorders are common to all cancer types (i.e. diuretic-induced hyponatremia or hypokalemia). Sometimes, electrolyte disorders are caused by paraneoplastic syndromes or are due to cancer therapy. Potassium is one of the most important electrolytes of the human body since it is involved in the regulation of muscle contraction, maintenance of the integrity of the skeleton, blood pressure and nerve transmission as well as in the normal function of cells. Potassium homeostasis is strictly regulated since the gap between the recommended daily dietary intake (120 mEq/day) and the levels stored in the extracellular fluid (around 70 mEq) is huge. Alterations of potassium homeostasis are frequent in cancer patients as well alterations in potassium channels, the transmembrane proteins that mediate potassium fluxes within the cells. The present chapter is focused on the clinical significance of potassium homeostasis and potassium channels in patients with solid tumors.

Tyrosine kinase inhibitors and tumor lysis syndrome in hematologic malignancies: A systemic review

BACKGROUND

Effective treatments for hematologic malignancies include therapies that target tyrosine kinase (TK) signaling pathways. Tumor lysis syndrome (TLS) is an oncologic emergency that can occur due to rapid turnover following the initiation of treatments for hematologic malignancy. The incidence of TLS is under-reported and it is unclear as to whether TK inhibitors (TKIs) are associated with TLS.

OBJECTIVE

To conduct a systematic review to determine the incidence of TLS with TKIs.

METHODS

A search was performed using EMBASE, MEDLINE, and Web of Science electronic databases, as well as a manual search of the American Society of Hematology and American Society of Clinical Oncology abstract databases. Keywords included: "tumor lysis syndrome," "tyrosine kinase inhibitors," "lymphoma," and "leukemia."

RESULTS

We identified a total of 57 publications that commented on the incidence of TLS with TKIs for hematologic malignancy. Thirty-nine of those publications reported TLS as an adverse event. TLS was described as an adverse event among essentially all the subclasses of TKIs that are used to manage hematologic malignancies.

CONCLUSION

The overall number of articles commenting on TLS as an adverse event is sparse and there needs to be more transparency regarding the incidence of TLS when employing newer targeted therapies. Physicians should consider the risk of TLS on an individual basis and the added risk of TLS when using TKIs to treat hematologic malignancy.

Concomitant Kinase-Dead BRAF and Oncogenic KRAS Lead to an Aggressive Biologic Behavior and Tumor Lysis Syndrome: A Case Report

Tumor lysis syndrome (TLS) is a life-threatening oncological emergency rarely seen in solid tumors and is a complication of cancer therapy for rapidly proliferating tumors with devastating outcomes. BRAF and KRAS are two key oncogenes in the MAPK signaling pathway that are routinely examined for mutations to predict resistance to anti-EGFR therapy. Concomitant KRAS and BRAF mutations in GI tumors are rare, occurring in less than 0.001% of cases and are associated with an aggressive tumor behavior. We report an unusual case of a young male patient diagnosed with locally advanced duodenal mucinous adenocarcinoma harboring concomitant KRAS and BRAF mutations. This unique genetic profile generated hyperactivation of the EGFR signaling pathway. Following day-1 of mFOLFOX-6 chemotherapy protocol, the patient developed TLS. Clinical resolution was achieved using high volume hydration. Unfortunately, the patient passed away 10 days later during anesthesia induction.

Tumor Lysis Syndrome: An Endless Challenge in Onco-Nephrology

Tumor lysis syndrome (TLS) is a common cause of acute kidney injury in patients with malignancies, and it is a frequent condition for which the nephrologist is consulted in the case of the hospitalized oncological patient. Recognizing the patients at risk of developing TLS is essential, and so is the prophylactic treatment. The initiation of treatment for TLS is a medical emergency that must be addressed in a multidisciplinary team (oncologist, nephrologist, critical care physician) in order to reduce the risk of death and that of chronic renal impairment. TLS can occur spontaneously in the case of high tumor burden or may be caused by the initiation of highly efficient anti-tumor therapies, such as chemotherapy, radiation therapy, dexamethasone, monoclonal antibodies, CAR-T therapy, or hematopoietic stem cell transplantation. It is caused by lysis of tumor cells and the release of cellular components in the circulation, resulting in electrolytes and metabolic disturbances that can lead to organ dysfunction and even death. The aim of this paper is to review the scientific data on the updated definition of TLS, epidemiology, pathogenesis, and recognition of patients at risk of developing TLS, as well as to point out the recent advances in TLS treatment.

A case report of tumor lysis syndrome after stage-one ALPPS

RATIONALE

Tumor lysis syndrome is a potentially lethal condition caused by rapid cell death, releasing a high level of toxic cytokines. It is common in patients with hematological malignancy but rare in solid tumors.

PATIENT CONCERNS

A 64-year-old patient presented to our unit with a 17.3-cm hepatocellular carcinoma and marginal liver reserve. The first-stage operation of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was performed.

DIAGNOSIS

The patient was found to be anuric with grossly deranged electrolytes after the first-stage operation. Tumor lysis syndrome was diagnosed.

INTERVENTIONS

The patient was transferred to the intensive care unit for aggressive fluid administration and continuous venovenous hemofiltration for the management of tumor lysis syndrome.

OUTCOMES

The patient recovered and then underwent the second-stage operation of ALPPS with extended right hepatectomy 8 days after the initial operation without any long-term sequelae.

LESSONS

ALPPS is a relatively new technique in liver surgery, entailing an increased risk of tumor lysis syndrome due to an in situ tumor after the first-stage operation. Clinicians should have a high index of suspicion regarding this potentially lethal complication with prompt management.

Spontaneous tumor lysis syndrome in adrenal adenocarcinoma: a case report and review of the literature

Background

Tumor lysis syndrome is an oncologic emergency that classically occurs following cancer therapy, although spontaneous tumor lysis syndrome can also occur in malignancies, albeit rarely. Spontaneous tumor lysis syndrome has previously been reported in some hematologic malignancies, but it rarely happens in solid tumors and seems to be associated with a higher mortality rate. This is the first case of adrenal adenocarcinoma that developed spontaneous tumor lysis syndrome.

Case presentation

We present a rare case of spontaneous tumor lysis syndrome occurring in a patient previously diagnosed with adrenal adenocarcinoma. The patient was a 64-year-old Persian man with abdominal pain, hypersomnia, and fatigue who was previously diagnosed with right adrenocortical carcinoma and had undergone right adrenalectomy with regional lymph nodes resection 5 months previously. On physical examination, the patient had abdominal distension and mild tenderness at the right upper quadrant. Pitting edema was detected bilaterally in the lower extremities. Initial imaging revealed multiple and large lesions suggestive of liver metastases. The laboratory data showed hyperkalemia, hyperuricemia, hyperphosphatemia, and elevated serum creatinine level indicative of spontaneous tumor lysis syndrome in the patient. Despite immediate and intensive care with antibiotics, hydration, treatment with a hypouricemic agent, and renal replacement therapy, the patient ultimately died from multiorgan failure.

Conclusions

Tumor lysis syndrome in solid tumors has high mortality. Patients susceptible to spontaneous tumor lysis syndrome must receive aggressive treatment immediately, which is crucial for preventing morbidity and mortality. Spontaneous tumor lysis syndrome may be underdiagnosed, and a high degree of clinical suspicion is needed to make the diagnosis and proceed with required interventions. Therefore, clinicians should be aware of this rare phenomenon.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-022-03263-4.

A Rare Case of Sarcomatoid Variant of Mixed Germ Cell Tumor of the Testis Presenting With Malignant Hypercalcemia and Tumor Lysis Syndrome

Hypercalcemia of malignancy is relatively common in several cancers. However, in testicular cancer, paraneoplastic hypercalcemia is uncommon. We describe the first case of severe tumor lysis syndrome associated with hypercalcemia from bone metastasis of testicular origin. Classically, tumor lysis syndrome is associated with hypocalcemia. This was a diagnostic and therapeutic challenge.

Fatal Tumour Lysis Syndrome Induced by Brigatinib in a Lung Adenocarcinoma Patient Treated With Sequential ALK Inhibitors: A Case Report

Tumour lysis syndrome (TLS) represents a group of fatal metabolic derangements resulting from the rapid breakdown of tumour cells. TLS typically occurs soon after the administration of chemotherapy in haematologic malignancies but is rarely observed in solid tumours. Here, we report a case of brigatinib-induced TLS after treatment with sequential anaplastic lymphoma kinase (ALK) inhibitors in a patient with advanced ALK-rearranged lung adenocarcinoma. The patient was treated sequentially with crizotinib, alectinib, and ensartinib. High-throughput molecular profiling after disease progression indicated that brigatinib may overcome ALK resistance mutations, so the patient was administered brigatinib as the fourth-line treatment. After 22 days of therapy, he developed oliguria, fever, and progressive dyspnoea. Clinical manifestations and laboratory findings met the diagnostic criteria for TLS. The significant decrease in the abundance of ALK mutations in plasma indicated a therapeutic response at the molecular level. Consequently, the diagnosis of brigatinib-induced TLS was established. To the best of our knowledge, this is the first case of TLS induced by sequential targeted therapy in non-small cell lung cancer. With the extensive application of sequential therapy with more potent next-generation targeted therapeutic drugs, special attention should be given to this rare but severe complication.

Orbital Cellulitis in a Patient With Sphenoid Wing Meningioma

We report a case of a 43-year-old woman with an underlying right sphenoid wing meningioma (SWM) who complained of increased right eye swelling, proptosis, redness and severe pain for two weeks. Her symptoms started one week after completing radiotherapy. She seeked treatment after a worsening of symptoms. An urgent computed tomography (CT) scan of the brain was done and showed increasing extension of tumour and hypodense areas within intraorbital region of the tumour with intraorbital fat stranding. She was treated as right eye orbital cellulitis with a differential diagnosis of tumour lysis syndrome. She was started on a combination of intravenous antibiotics and improvements were noticed after two days of treatment. This report presents the diagnostic challenge in managing orbital swelling in a patient with sphenoid wing meningioma with inconclusive radiological findings. Orbital cellulitis is an ocular emergency that requires prompt treatment and can potentially be vision and life-threatening, if not addressed early. In such cases with diagnostic dilemma, the decision to treat should be made as early as possible.

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.

Spontaneous Tumor Lysis Syndrome in Prostate Cancer

Tumor lysis syndrome (TLS) is an oncological emergency that most frequently occurs in hematological and high-turnover solid neoplasia. Its incidence in solid, slowly proliferating neoplasia is unclear, primarily because of few published case reports. TLS may be triggered by chemotherapy or infection, or may spontaneously arise. Here, we present a review of the literature and a case of a 58-year-old male patient with prostate cancer who developed spontaneous TLS.

Tumor lysis syndrome in advanced and high-grade endometrial cancers: A case report and review of the literature

•

Tumor lysis syndrome is a rare but deadly complication of solid tumors.

•

We suggest that tumor lysis syndrome is especially deadly when it results from high grade or metastatic endometrial cancers.

•

Consider prophylactic measures to prevent tumor lysis syndrome in high risk patients before initiating therapy.

Preoperative Low Serum Calcium Levels Predict Poor Prognosis for Patients with Esophageal Cancer

Purpose: Hypercalcemia has been reported as a poor prognostic factor in malignant tumors. However, no report has shown the clinical impact of serum calcium levels on patients with esophageal cancer. We evaluated the prognostic impact of preoperative serum calcium levels on patients with esophageal cancer.

Methods: We evaluated 240 patients (197 men, 43 women; mean age, 66 years; age range, 34–85 years) with esophageal cancer who underwent radical surgery between September 2008 and December 2017. After assigning the patients to two groups (high calcium group, 8.8 mg/dL or more and low calcium group, 8.7 mg/dL or less), we compared the groups’ overall survival and the clinicopathological features. The clinicopathological and prognostic significance of preoperative serum calcium levels were evaluated in a univariate and multivariate analysis.

Results: The patients with deep tumors showed low serum calcium levels significantly more frequently (P <0.05). The low calcium group showed a significantly worse prognosis than the high calcium group (P <0.05). However, low serum calcium level was not an independent poor prognostic factor.

Conclusions: Preoperative low serum calcium levels were associated with advanced tumors. Low serum calcium might be associated with esophageal cancer progression.

Tumor lysis Syndrome in a Patient with Metastatic Breast Cancer Treated with Alpelisib

Purpose:

Tumor lysis syndrome (TLS) is a rare but life-threatening phenomenon that occurs mainly in patients with aggressive hematologic or highly chemotherapy sensitive solid tumors such as high-grade neuroendocrine carcinoma or testicular cancer. Tumor lysis syndrome is exceedingly rare in hormone receptor-positive, HER2-negative breast cancer. Furthermore, TLS following treatment with alpelisib, a novel phosphatidylinositol 3-kinase (PI3K) inhibitor used to treat PIK3CA-mutated (gene encoding p110α subunit of PI3K), hormone receptor positive advanced breast cancer, has never been described in patients with nonhematologic malignancies.

Methods:

In the following case, we present a patient with hormone receptor-positive, HER2-negative, PIK3CA-mutated metastatic breast cancer who developed TLS 12 days after starting fulvestrant and alpelisib.

Results:

Patient was promptly treated with improvement in her renal function to baseline without requiring renal replacement therapy. Alpelisib was resumed at a reduced dose with no further complications.

Conclusion:

Through this case, we discuss the potential complications of TLS and the importance of prompt recognition and treatment.

Tumour Lysis Syndrome in Occult Breast Cancer Treated With Letrozole - A Rare Occurrence. A Case Report and Review

Tumour lysis syndrome (TLS) is a medical emergency occurring when large numbers of cancer cells rapidly undergo cell death. The resultant metabolic abnormalities results in significant morbidity and mortality. Tumour lysis syndrome most commonly occurs in 5% of haematological malignancies and is less commonly described in solid organ cancers. In breast cancer, TLS has been reported to occur both spontaneously and as a result of cancer chemotherapy, targeted therapy, or radiotherapy. However, only 1 TLS case in a breast cancer patient has been reported as a consequence of aromatase inhibitor letrozole. With the increased recent use of CDK4/6 inhibitors, 2 cases of hyperuricaemia in patients with breast cancer treated with palbociclib/letrozole combination treatment have also been reported. We present the second case of letrozole-induced TLS in a 74-year-old woman with occult breast adenocarcinoma. Despite treatment with recombinant urate oxidase and intravenous fluids, the patient deteriorated and was discharged with hospice care. Although rare, this life-threatening condition should be considered in an acutely unwell patient commencing treatment for solid malignant tumours.

Mechanisms of Cisplatin-Induced Acute Kidney Injury: Pathological Mechanisms, Pharmacological Interventions, and Genetic Mitigations

Administration of the chemotherapeutic agent cisplatin leads to acute kidney injury (AKI). Cisplatin-induced AKI (CIAKI) has a complex pathophysiological map, which has been linked to cellular uptake and efflux, apoptosis, vascular injury, oxidative and endoplasmic reticulum stress, and inflammation. Despite research efforts, pharmaceutical interventions, and clinical trials spanning over several decades, a consistent and stable pharmacological treatment option to reduce AKI in patients receiving cisplatin remains unavailable. This has been predominately linked to the incomplete understanding of CIAKI pathophysiology and molecular mechanisms involved. Herein, we detail the extensively known pathophysiology of cisplatin-induced nephrotoxicity that manifests and the variety of pharmacological and genetic alteration studies that target them.

Urate Nephropathy from Tumor Lysis Syndrome in an Undiagnosed Case of Prostate Cancer

Prostate cancer can masquerade as just normocytic anemia and thrombocytopenia, thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), or tumor lysis syndrome (TLS). We are reporting an intriguing case of metastatic prostate cancer which remained undiagnosed until the patient showed signs of tumor lysis syndrome (TLS), leading to urate nephropathy requiring urgent hemodialysis. Tumor lysis syndrome is an oncological emergency but an exceedingly rare complication in non-hematological malignancies, including prostate cancer. It is challenging to recognize features of TLS in a case such as this with an unknown diagnosis. In the case of an established diagnosis of malignancy, however, checking baseline renal function, uric acid, lactate dehydrogenase (LDH), potassium, and phosphate to monitor for TLS as well as considering urate lowering therapy can help prevent adverse outcomes.

Fatal tumor lysis syndrome in a patient with metastatic gastric adenocarcinoma

Tumor lysis syndrome is a well-characterized and potentially deadly complication of spontaneous or treatment-related tumor destruction, and it is most commonly associated with hematologic malignancies. Our case illustrates a rare example of fatal tumor lysis syndrome in the setting of metastatic gastric adenocarcinoma treated with radiation therapy. This case highlights the critical importance of identifying patients with solid organ malignancies at risk for tumor lysis syndrome and of early recognition and treatment of this syndrome.

Spontaneous Tumor Lysis Syndrome

Tumor lysis syndrome (TLS) is a hemato-oncological emergency characterized by metabolic and electrolyte imbalances which are associated with disintegrating tumor cells. The syndrome is frequently observed when starting cytotoxic treatment of hematological malignancies, while the incidence of spontaneous tumor lysis prior to the start of tumor therapy is rare. Here, we present a case of spontaneous TLS in a male patient who was referred with unspecific symptoms and suspected metastatic malignancy. He developed acute renal failure before the diagnosis of a high-grade B-cell lymphoma (double hit lymphoma) and start of therapy. Although the course of TLS would have required intensive care, the patient rejected such treatment for personal reasons and died soon after the discontinuation of therapy. The case emphasizes the life-saving relevance of early detection and appropriate treatment of TLS. It also demonstrates the importance of actively screening for TLS, primarily in patients with malignant diseases and high tumor load, even if they are not receiving cytotoxic therapy.

Tumor Lysis Syndrome After a Single Dose of Atezolizumab with Nab-Paclitaxel: A Case Report and Review of Literature

Patient: Female, 55-year-old

Final Diagnosis: Metastatic breast cancer • tumor lysis syndrome

Symptoms: Anorexia • lethargy • oliguria • weakness

Medication: —

Clinical Procedure: —

Specialty: Oncology

A case of spontaneous tumor lysis syndrome in extensive-stage small-cell lung cancer: A rare oncologic emergency

Tumor lysis syndrome (TLS) is an oncologic emergency. It generally occurs after chemotherapy but sometimes develops spontaneously in hematologic malignancy, such as leukemia. TLS is a rare phenomenon in patients with solid tumors, particularly when it develops spontaneously. Here, we present a case of spontaneous TLS (STLS) in a patient with small-cell lung cancer (SCLC). We report a case of STLS in a 59-year-old male patient who presented with dyspnea and oliguria. Clinicians should suspect TLS in patients with malignancy, who demonstrate the classic electrolyte abnormalities of TLS even if not receiving treatment such as chemotherapy or radiotherapy.

Fatal Spontaneous Tumor Lysis Syndrome in a Patient with Metastatic Colon Cancer: A Clinical Case of Rare Oncological Emergency

Tumor lysis syndrome (TLS) is a potentially life-threatening complication of chemotherapy. It usually occurs in rapidly proliferating hematological malignancies. TLS is deemed spontaneous (STLS) when it occurs prior to any cytotoxic or definite treatment. STLS is extremely rare in solid tumors. Here, we report a rare case of fatal STLS in a 47-year-old woman diagnosed with metastatic colon cancer. The patient developed acute renal failure with anuria, electrolyte disturbances, and metabolic acidosis before initiating chemotherapy. Despite appropriate management of TLS, including renal replacement therapy, she died within a few days from multiorgan failure. Only few other case reports of STLS associated with colon cancer have been reported in the literature.

Pembrolizumab-axitinib-induced tumor lysis syndrome in a patient with metastatic renal cancer

Tumor lysis syndrome is uncommon in solid tumors but with the use of immunotherapy (checkpoint inhibitors) their incidence is increasing. Physicians need to take adequate precautions while treating patients with immunotherapy. The findings of our case report will help improve our current understanding of tumor lysis syndrome specially in solid tumors and will help in developing multidisciplinary treatment and prophylaxis strategies for this uncommon, but potentially fatal complication.

Intricate Interplay of Entwined Metabolic and Inflammatory Life-threatening Processes in Tumor Lysis Syndrome Complicating Prostate Cancer: A Systematic Review with a Single Institution Experience

Tumor lysis syndrome (TLS) occurs in rapidly proliferating tumor cells, either spontaneously or after cytotoxic therapy. It has been well-documented in hematological diseases but is extremely rare in solid neoplasms, particularly in prostate cancer (PRCA). In the presence of risk factors, it can cause metabolic disturbances and be potentially fatal. We searched PubMed, Medline, ScienceDirect, and Scopus for "tumor lysis syndrome" and "prostate cancer" and conducted a systematic review with a pooled analysis for the published literature and cases from our institution. Twenty-two TLS cases were identified (18 published in the literature and four cases from our institution). The patients' median age was 68 years (range 16-82), and most cases were prostate adenocarcinoma. The median prostate-specific antigen (PSA) was 374 (range 66.7-10,867). Ten cases (45.5%) had spontaneous TLS (STLS) while 12 cases (54.5%) were treatment-related (TTLS). All patients had elevated lactate dehydrogenase (LDH) with other biochemical variables, and all underwent aggressive supportive therapy. Eleven patients underwent hemodialysis, 12 patients received rasburicase, while three patients received allopurinol. The mortality rate was 75% among 12 cases of TTLS, and it was 30% of the 10 cases with STLS. Among patients with PRCA, both TTLS and STLS linked to very high mortality. Early identification of TLS would substantially attain improved survival outcomes. Hence, physicians should consider TLS as a differential diagnosis when evaluating AKI and electrolyte abnormalities, particularly in patients with metastatic PRCA and high disease burden, even before the initiation of cytotoxic therapy.

DNA-nanorobot-guided thrombin-inducing tumor infarction: raising new potential clinical concerns

DNA-nanorobot-guided thrombin-inducing tumor infarction (DNA NanorobotTh-ITI) is emerging as a powerful therapeutic strategy for treatment of solid cancers. The technology represents a major advance in the application of DNA nanotechnology for anticancer therapy. More importantly, the technology is being translated from preclinical studies to the clinic owing to its promising anticancer effects with fewer toxicities demonstrated in preclinical settings. However, despite these beneficial effects of the technology, it is important to point out that some important potential clinical concerns remain to be addressed. Here, we raise these clinical concerns along with these beneficial effects of the technology. Hopefully, these newly raised potential clinical concerns could drive forward research in this field to expedite its clinical translation.

A rare cause of tumour lysis syndrome and acute kidney injury

Tumour lysis syndrome is rare in solid malignancies. Here, we report a case of tumour lysis syndrome and acute kidney injury in a 23-year-old female with gestational trophoblastic neoplasia. Hydration and early dialysis therapy were started with good recovery. On follow up she progressed to chronic kidney disease. After 6 years of follow up, the patient conceived and delivered successfully.

Tumour lysis syndrome in patients with chronic lymphocytic leukaemia treated with BCL-2 inhibitors: risk factors, prophylaxis, and treatment recommendations

Tumour lysis syndrome is a complication of chemotherapy for haematological malignancies; in particular, aggressive leukaemias and lymphomas. For haematological malignancies, targeted therapies, such as small molecule inhibitors and monoclonal antibodies, have a high anti-tumour activity, are well tolerated, and have a low incidence of associated tumour lysis syndrome. The BCL-2 inhibitor venetoclax has a high anti-tumour activity in chronic lymphocytic leukaemia, achieving deep remissions by potently inducing apoptosis and increasing the risk for tumour lysis syndrome. In this Viewpoint, we discuss the pathophysiology, risk factors, monitoring, changes in laboratory parameters, and clinical manifestations of tumour lysis syndrome, and the prophylaxis and treatments available for this complication. Prophylaxis and treatment strategies have been implemented as standard of care in patients receiving venetoclax to minimise the risk of both laboratory and clinical manifestations of tumour lysis syndrome.

Hypocalcemia in cancer patients: An exploratory study

Introduction

Calcium has several physiological functions and when it registers abnormal serum levels those functions may be impacted with potentially severe consequences. There is much research on hypercalcemia in cancer patients, but there are no recent studies on the prevalence of hypocalcemia in those patients. However, there has been an evolution in oncology, namely, new drugs that may directly or indirectly result in hypocalcemia. The primary aim was to explore the association of hypocalcemia with the diverse types of cancer. The secondary aim was to study the influence that hypocalcemia might have on survival.

Methods

Review of the records of patients ≥18 years old, with total calcium <2.0 mmol/L measured in 2013 in a cancer center.

Results

Eight hundred twenty-nine patients were included. Four hundred thirty-nine (53%) were male. The median age was 63 years. The most frequent cancer diagnoses were hematological 196 (24%) and colorectal 111 (13%). Six hundred thirty-eight patients had measured serum albumin, with a median of 25.5 g/L (14-47). When corrected for albumin level, calcium was in the normal range in 210 (33%) cases. The median survival of patients with corrected calcium lower than normal was 479 days (95% confidence interval [CI]: 309-649) and that of patients with normal corrected calcium was 62 days (95% CI: 33-91), P < .001. In a multivariate analysis, age, primary cancer, and albumin were significantly associated with survival.

Conclusion

Hypocalcemia is associated with several types of cancer. A low calcium level is not by itself a factor of a poor prognosis since other factors seem to be more important.

Fasting Serum Levels of Potassium and Sodium in Relation to Long-Term Risk of Cancer in Healthy Men

Purpose

To examine whether serum levels of potassium and sodium were associated with long-term cancer risk in initially healthy men.

Patients and Methods

A cohort of 1994 initially healthy men with no use of medication, aged 40–59 years, was followed for cancer during 40 years of follow-up. Associations between fasting electrolyte levels and cancer risk were assessed with incidence rates and Cox proportional hazards models.

Results

Potassium, but not sodium, was linearly associated with cancer risk. This association remained significant after adjustment of several potential confounding factors, and also after excluding the first 10 years of follow-up. The age-adjusted risk of all-site cancer increased with 16% for each SD increase in potassium level. Men with hyperkalemia showed an incidence rate that was 40% higher than for men with normal potassium levels.

Conclusion

Fasting serum potassium level in healthy men was positively associated with long-term cancer risk. Potassium or potassium ion channels may have a role in cell proliferation or differentiation. These findings might imply future cancer strategies for targeting individuals with high serum potassium levels.

[Unusual Cause of Acute Kidney Failure in a Patient with Metastatic Bladder Carcinoma Undergoing Palliative Chemotherapy]

Unusual Cause of Acute Kidney Failure in a Patient with Metastatic Bladder Carcinoma Undergoing Palliative Chemotherapy Abstract. Tumour lysis syndrome is a potentially life-threatening complication of cancer and its treatment. It mostly occurs in highly proliferative haematological neoplasms under cytotoxic therapy but can also be seen spontaneously and in solid neoplasms, particularly with high tumour burden and/or high chemosensitivity. The present case report describes a tumour lysis syndrome in a patient with metastatic bladder cancer with an elevated lactate dehydrogenase as only potential correlate of a high tumour burden.

Tumor Lysis Syndrome in a Patient With Gastric Adenocarcinoma

Tumor lysis syndrome (TLS) is a severe metabolic complication that usually occurs in patients with aggressive tumors who undergo treatment with chemotherapy. Traditionally, it was mainly associated with hematologic malignancies. However, over the past 4 decades, there have been increasing reports of TLS in solid tumors. We report a case of TLS in a patient with gastric cancer, as a complication of FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) chemotherapy. Our patient was a 48-year-old man with metastatic gastric adenocarcinoma who presented with altered mental status and slurred speech. On examination, he was confused and disoriented, but the rest of his examination, including vitals, was unremarkable. Laboratory findings on admission were significant for an elevated uric acid of 14.5 mg/dL, creatinine of 4.1 mg/dL, and phosphorus of 6.9 mg/dL. He had received his first cycle of FOLFOX chemotherapy 4 days prior to admission. The constellation of electrolyte abnormalities and the temporal relationship to chemotherapy led to the diagnosis of chemotherapy-induced TLS. He was treated with aggressive fluid repletion and rasburicase, following which the electrolyte derangements resolved, and he improved clinically. This case highlights the importance of early recognition of TLS in patients with gastric cancer. Initiation of early treatment can reduce the high morbidity and mortality associated with this oncologic emergency.

Acute Liver Failure as the Leading Manifestation of Spontaneous Tumour Lysis Syndrome in a Patient with NonHodgkin Lymphoma: Do Current Diagnostic Criteria of Tumour Lysis Syndrome Need Re-Evaluation?

Tumour lysis syndrome (TLS) is a group of pathophysiological processes caused by rapid degradation of tumour cells with subsequent release of intracellular contents into the extracellular space. It is characterized by the development of systemic metabolic disturbances with or without clinical manifestations. The process usually occurs in highly proliferative, large tumours after induction of cytotoxic therapy. Rarely, however, spontaneous TLS can develop, as well as signs of multiorgan failure triggered by an excessive metabolic load and sterile inflammation. The combination of the aforementioned is thus quite unique. Here, we present a 63-year-old male in which spontaneous TLS was accompanied with acute liver failure and delineated underlying nonHodgkin lymphoma. Initial laboratory findings included hyperkalaemia, hyperphosphataemia, hypocalcaemia, uraemia, and increased creatinine levels indicating the onset of TLS with acute kidney injury. Moreover, the patient showed signs of jaundice, coagulopathy, and hepatic encephalopathy. Development of TLS with multiorgan failure prompted rapid initiation of critical care management, including vigorous intravenous fluid therapy, allopurinol treatment, high flow continuous venovenous haemodiafiltration, and commencement of chemotherapy. The case highlights the possibility of TLS as a differential diagnosis in patients presenting with multiorgan failure and the importance of early detection of this potentially challenging and fatal diagnosis.

Circulating intranuclear proteins may play a role in development of disseminated intravascular coagulation in individuals with acute leukemia

Intranuclear proteins, including high mobility group box 1 (HMGB1) and histone H3, released from inflammatory cells activate platelets and the coagulation systems, leading to development of disseminated intravascular coagulation (DIC) in individuals with sepsis. These observations prompted us to hypothesize that HMGB1 and histone H3 liberated from leukemia cells undergoing apoptosis after chemotherapy might play a role in development of DIC. To test this hypothesis, we prospectively measured plasma levels of coagulation markers and intranuclear proteins in patients with newly diagnosed acute leukemia (n = 17) before and after chemotherapy. Ten of 17 patients were diagnosed with DIC at the time of diagnosis of leukemia. Serum levels of HMGB1 and histone H3 were significantly higher in patients with DIC than in non-DIC patients. Of note, seven patients developed DIC or experienced exacerbation of coagulopathy after administration of anti-leukemic agents. Intriguingly, an increase in levels of HMGB1 and histone H3 were detected in five of seven patients. These findings suggest that intranuclear proteins spontaneously released from leukemia cells may play a role in development of leukemia-related DIC. Additionally, remission induction chemotherapy causes apoptosis of leukemia cells, leading to forced release of intranuclear proteins, which may exacerbate coagulopathy.

Tumor lysis syndrome in gynecologic cancers: An uncommon but important diagnosis to recognize

•

TLS treated with rasburicase is rare and associated with approximately 5% of gynecologic cancers.

•

TLS is most frequently associated with new diagnosis of high-grade gynecologic malignancies.

•

The most common presenting symptoms of TLS include acute kidney injury and electrolyte derangement.

•

Early recognition and treatment of TLS can rapidly improve uric acid and electrolyte derangements.

Objectives

To describe the incidence, treatment and outcomes associated with tumor lysis syndrome (TLS) in women with gynecologic cancer (GOC).

Methods

A retrospective multi-institutional review of TLS associated with GOC. Women presenting with an elevated serum uric acid managed with intravenous (IV) rasburicase were included. Descriptive statistics of patient demographics, clinical findings, and outcome data was completed.

Results

From two large academic institutions N = 18 patients were found to meet inclusion criteria from 2008 to 2018, reflecting an approximate 5% incidence of clinically treated TLS associated with GOC in our cohort. Median age was 60 years, a majority were Caucasian (n = 11, 61.1%), median BMI was 36.2. TLS was associated with a high-grade GOC in n = 17 (94.4%) cases. TLS was commonly diagnosed with a new GOC (n = 12, 70.6%) and following receipt of chemotherapy in n = 9 (50.0%) cases. Six (66.7%) patients were treated with paclitaxel or combination, five (55.5%) with a platinum or combination, and two (22.2%) with a CD47 inhibitor. Chief complaints included electrolyte and renal abnormalities (n = 11, 73.3%). Peak serum uric acid, potassium, creatinine and phosphorus levels were 14.1 mg/dL, 5.7 mEq/L, 5.1 mg/dL, and 6.8 mg/dL, respectively. Nine patients received hospice during their admission with 3 (20%) deaths occurring as inpatients. There were 12 deaths with median OS of 16 d (range: 2–87 d).

Conclusions

Though rare, TLS can be associated with GOC. Early recognition of presenting symptoms, laboratory findings and expedited treatment may help with electrolyte recovery; however, TLS associated with GOC may herald a rapidly deteriorating state with significant associated mortality.