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Tumor Lysis Syndrome in an Unusually Presenting Fatal Case of Small Cell Lung Cancer: A Case Report
Soheila Fayeghi Azghadi1, Gerald Diaz2, Niousha Chalpapagh3, and Stephan Henry2
1UC
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.
Davis School of Medicine, 2Department of Internal Medicine, 3 De Ocampo Memorial College
University of California Davis, Sacramento, CA, 95817, USA
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, PO4 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
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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. eCollection 2014 May 13. Review. PubMed
PMID: 25002953; PubMed Central PMCID: PMC4083673.
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. PubMed PMID: 24454007; PubMed Central PMCID: PMC3893332.
3: McBride 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. PubMed PMID: 23237230; PubMed
Central PMCID: PMC3544586.
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. PubMed 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. PubMed
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. PubMed
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. PubMed PMID: 24359983; PubMed Central PMCID: PMC4017246.
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. PubMed 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. PubMed 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/hcn129.
Epub 2008 Oct 1. PubMed 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.