YAJEM-56716; No of Pages 2 American Journal of Emergency Medicine xxx (2017) xxx–xxx
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Case reports
Treatment-naïve spontaneous tumor lysis syndrome in metastatic prostate adenocarcinoma: An unusual suspect Maya Ignaszewski, MD ⁎, Patrick Kohlitz, MD Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, United States
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Article history: Received 4 May 2017 Accepted 26 May 2017 Available online xxxx Keywords: Tumor lysis syndrome Hyperuricemia Rasburicase Metastatic prostate cancer
a b s t r a c t Tumor lysis syndrome (TLS) is a potentially fatal condition defined both by laboratory and clinical criteria. It is caused by the catabolism of tumor cells which leads to considerable release and elevated levels of phosphate, potassium and uric acid in the bloodstream. These electrolyte derangements predispose patients to renal tubule uric acid precipitation, acute kidney injury, arrhythmias, neuromuscular irritability and even seizures. Although this phenomenon is well described with hematological malignancies, it is also known to occur among solid tumors. We present a rare case of treatment-naïve spontaneous TLS that occurred in a 69-year-old male with metastatic prostate adenocarcinoma with hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, elevated liver enzymes, AKI and hemodynamic instability. Despite our best resuscitative efforts with intravenous hydration, electrolyte monitoring, Rasburicase and renal replacement therapy, the patient continued to decline, was made comfort care and expired shortly thereafter. Physicians encountering patients with the above presentation must entertain a diagnosis of TLS despite its rarity in solid tumors, as early diagnosis leads to timely treatment, thereby maximizing patients' chances at survival. © 2017 Elsevier Inc. All rights reserved.
Tumor lysis syndrome is an oncological emergency that occurs as a consequence of rapid neoplastic cell turnover leading to metabolic derangements such as hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia and acute renal failure. It is most commonly seen after initiation of chemotherapy in hematologic malignancies; however, spontaneous TLS in the absence of chemotherapy in solid tumors has also been reported, although rare. We present an unusual case of treatment-naïve spontaneous TLS in a patient with metastatic prostate adenocarcinoma. A 69-year-old male with past medical history most significant for hypertension, hyperlipidemia and stage IV prostate adenocarcinoma with metastasis to the spine and liver initially presented to the emergency department with nausea, vomiting, weakness, dizziness and abdominal pain. On arrival, the patient was hypotensive to 86/60 with a pulse of 120, respiratory rate of 27 and 92% oxygen saturation on 4L nasal cannula. Physical examination revealed dry oral mucosa, tachycardia, tachypnea, abdominal distension and hepatomegaly. The patient was in respiratory distress with accessory muscle usage and as a result, was intubated in the ED. Laboratory work revealed sodium of 121, potassium of 6.4, bicarbonate of 15, BUN of 90, creatinine of 5.9 (previously normal), magnesium of 2.5, phosphorus of 9.3, lactate dehydrogenase of Abbreviations: TLS, tumor lysis syndrome; ED, emergency department. ⁎ Corresponding author. E-mail addresses:
[email protected] (M. Ignaszewski),
[email protected] (P. Kohlitz).
1050, uric acid of 14.7, total bilirubin of 4.5, alkaline phosphatase of 710, ALT of 306 and AST of 410. Abdominal imaging revealed significant tumor burden in the liver with extension into the spine. The patient was admitted to the Medical ICU for further care. Hematology/Oncology was consulted and together with the patient's new oliguria and varying laboratory abnormalities, a diagnosis of TLS was made. Nephrology was consulted, the patient was started on IV fluids with bicarbonate, given a dose of Rasburicase and a vascular catheter was placed to start urgent dialysis. Despite aggressive resuscitative efforts, the patient continued to decline with worsening hemodynamic instability. Discussions were held with the family who elected to make the patient comfort care and he expired shortly thereafter. To our knowledge, this is only the second reported case of spontaneous TLS occurring in treatment-naïve metastatic prostate adenocarcinoma. This highlights not only the rarity of this disease, but also serves as evidence that solid tumors with high tumor burden can predispose a patient to this potentially fatal condition. Other predisposing risk factors may include decreased renal function, electrolyte disorders including hyperkalemia, hyperphosphatemia, hyperuricemia, sensitivity to cytotoxic medications and possibly even liver metastasis [1,2]. Treatment for TLS focuses largely on preventive therapy in patients who are at moderate to high risk with initiation of chemotherapy or radiation therapy. However, if there is an established diagnosis of TLS, treatment includes aggressive intravenous hydration, management of electrolyte abnormalities including use of Rasburicase to promote oxidation of uric acid to Allantoin, and in select cases, renal replacement therapy [3].
http://dx.doi.org/10.1016/j.ajem.2017.05.044 0735-6757/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Ignaszewski M, Kohlitz P, Treatment-naïve spontaneous tumor lysis syndrome in metastatic prostate adenocarcinoma: An unusual suspect, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.05.044
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M. Ignaszewski, P. Kohlitz / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Clinicians must be vigilant in entertaining a diagnosis of TLS when faced with abnormal laboratory work up despite this condition being most commonly seen among hematologic malignancies. Prompt recognition and timely initiation of aggressive treatment is paramount to improving patient survival in this otherwise destructive and potentially fatal syndrome.
Conflict of interest disclosure No conflicts of interest. No financial disclosures.
Acknowledgements None. 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;6:5389. [2] Serling-Boyd N, Quandt Z, Allaudeen N. Spontaneous tumor lysis syndrome in a patient with metastatic prostate cancer. Mol Clin Oncol 2017;6(4):589–92. [3] Cairo MS, Coiffier B, Reiter A, Younes A. Recommendations for the evaluation of risk and prophylaxis of tumor lysis syndrome (TLS) in adults and children with malignant disease; an expert TLS panel consensus. Br J Haematol 2010;149(4):578.
Please cite this article as: Ignaszewski M, Kohlitz P, Treatment-naïve spontaneous tumor lysis syndrome in metastatic prostate adenocarcinoma: An unusual suspect, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.05.044
