Tumor Lysis Syndrome in an Unusually Presenting Fatal

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Tumor Lysis Syndrome in an Unusually Presenting Fatal Case of Small Cell Lung Cancer:

Tumor Lysis Syndrome in an Unusually Presenting Fatal Case of Small Cell Lung Cancer: A Case Report Soheila Fayeghi Azghadi 1, Gerald Diaz 2, Niousha Chalpapagh 3, and Stephan Henry 2 1 UC Davis School of Medicine, 2 Department of Internal Medicine, 3 De Ocampo Memorial College University of California Davis, Sacramento, CA, 95817, USA Introduction Tumor lysis syndrome (TLS) is a potentially serious complication of anticancer therapy most often associated with initiation of treatment for rapidly growing, treatment-sensitive tumors, especially high-grade lymphomas and acute leukemias. TLS in untreated solid tumors is rare. CASE A 52 -year-old woman presented to the Emergency Department with 4 weeks of worsening epigastric pain, anorexia, fatigue, jaundice, and increased abdominal girth. She denied any dyspnea, fever, cough, or chest pain. She had no notable past medical history and took no medications. She worked as a physical therapist and had no history of tobacco or alcohol use. On presentation, she was afebrile with mild tachycardia. Physical exam was notable for cachexia and a protuberant, firm abdomen suggestive of massive hepatomegaly. Case Cont. In the Emergency Department: -CT of her chest and abdomen revealed diffuse confluent hepatic lesions, a right hilar mass, and numerous mediastinal and supraclavicular lymph nodes concerning for metastatic disease. -Brain MRI showed numerous ring enhancing masses throughout the cerebral and cerebellar hemispheres and the brainstem. Her admission labs were remarkable for elevated liver function tests. -Bronchoscopy and biopsy were performed and showed small cell lung cancer (SCLC). She was started on dexamethasone to reduce intercranial edema. -Given the advanced nature of her disease, oncology initiated inpatient chemotherapy treatment with Carboplatin and Etoposide. During the 4 days between admission and initiation of chemotherapy, the patient developed worsening abdominal pain, confusion, and weakness; Her bilirubin, Alkaline Phosphatase, liver function tests, and potassium became increasingly elevated. Case Cont. Her labs prior to starting chemotherapy were consistent with TLS, including K 5. 7, uric acid 10. 5, LDH 2645, PO 4 6. 1. She was started on carboplatin/etoposide chemotherapy. On day 3 of treatment, she developed respiratory distress and worsening confusion requiring transfer to the ICU and intubation. She was started on broad spectrum antibiotics. Blood cultures grew Klebsiella pneumoniae. Head CT showed hemorrhagic conversion of CNS lesions in the left hippocampus multiple new brain metastases. After extensive conversations with the patient’s family, she was transitioned to comfort care and died shortly thereafter. -New hemorrhagic within metastatic lesions in the left hippocampus. -Interval increase in prominence of numerous brain metastases. -New bifrontal subdural fluid collections. RESEARCH POSTER PRESENTATION DESIGN © 2012 www. Poster. Presentations. com Conclusion In this case, a patient with widely-metastatic SCLC developed TLS prior to treatment, which then worsened after initiation of chemotherapy. The incidence of TLS in SCLC is rare. Our literature search revealed 10 case reports of SCLC-associated TLS; however, we found no case reports of TLS developing prior to treatment in patients with new SCLC. TLS prior to chemotherapy is very rare, and may be due to autolysis associated with high tumor burden and rapid cell turnover. Patients presenting with widely metastatic SCLC are at relatively risk for TLS, and should be carefully monitored for TLS during and immediately after initiation of chemotherapy. References 1: Mirrakhimov AE, Ali AM, Khan M, Barbaryan A. Tumor Lysis Syndrome in Solid Tumors: An up to Date Review of the Literature. Rare Tumors. 2014 Jun 13; 6(2): 5389. doi: 10. 4081/rt. 2014. 5389. e. Collection 2014 May 13. Review. Pub. Med PMID: 25002953; Pub. Med Central PMCID: PMC 4083673. 2: Lee JY, Lim SH, Lee JY, Kim JH, Choi KH, Park K, Sun JM, Ahn JS, Ahn MJ. Tumor lysis syndrome in a solid tumor: a case report of a patient with invasive thymoma. Cancer Res Treat. 2013 Dec; 45(4): 343 -8. doi: 10. 4143/crt. 2013. 45. 4. 343. Epub 2013 Dec 31. Pub. Med PMID: 24454007; Pub. Med Central PMCID: PMC 3893332. 3: Mc. Bride A, Westervelt P. Recognizing and managing the expanded risk of tumor lysis syndrome in hematologic and solid malignancies. J Hematol Oncol. 2012 Dec 13; 5: 75. doi: 10. 1186/1756 -8722 -5 -75. Review. Pub. Med PMID: 23237230; Pub. Med Central PMCID: PMC 3544586. 4: Baeksgaard L, Sørensen JB. Acute tumor lysis syndrome in solid tumors--a case report and review of the literature. Cancer Chemother Pharmacol. 2003 Mar; 51(3): 187 -92. Epub 2003 Feb 28. Pub. Med PMID: 12655435. 5: Kalemkerian GP, Darwish B, Varterasian ML. Tumor lysis syndrome in small cell carcinoma and other solid tumors. Am J Med. 1997 Nov; 103(5): 363 -7. Review. Pub. Med PMID: 9375703. 6: Yarpuzlu AA. A review of clinical and laboratory findings and treatment of tumor lysis syndrome. Clin Chim Acta. 2003 Jul 1; 333(1): 13 -8. Review. Pub. Med PMID: 12809731. 7: Wilson FP, Berns JS. Tumor lysis syndrome: new challenges and recent advances. Adv Chronic Kidney Dis. 2014 Jan; 21(1): 18 -26. doi: 10. 1053/j. ackd. 2013. 07. 001. Review. Pub. Med PMID: 24359983; Pub. Med Central PMCID: PMC 4017246. 8: Coiffier B. Acute tumor lysis syndrome - a rare complication in the treatment of solid tumors. Onkologie. 2010; 33(10): 498 -9. doi: 10. 1159/000320581. Epub 2010 Sep 6. Pub. Med PMID: 20926895. 9: Theodorou D, Lagoudianakis E, Pattas M, Drimousis P, Tsekouras DK, Genetzakis M, Katergiannakis V, Manouras A. Pretreatment tumor lysis syndrome associated with bulky retroperitoneal tumors. Recognition is the mainstay of therapy. Tumori. 2006 Nov-Dec; 92(6): 540 -1. Pub. Med PMID: 17260497. 10: Shenoy C. Acute spontaneous tumor lysis syndrome in a patient with squamous cell carcinoma of the lung. QJM. 2009 Jan; 102(1): 71 -3. doi: 10. 1093/qjmed/hcn 129. Epub 2008 Oct 1. Pub. Med PMID: 18829711. Acknowledgment UC Davis School of Medicine , Department of Internal Medicine UC Davis Comprehensive Cancer Center UC Davis Department of Radiation Oncology And the patient’s family for allowing us to use this data for education purposes.