J Gastrointest Canc DOI 10.1007/s12029-014-9632-9
CASE REPORT
Spontaneous Acute Tumour Lysis Syndrome in Gastric Adenocarcinoma: A Case Report and Literature Review Hemant Goyal & Harinder Sawhney & Swetha Bekara & Umesh Singla
# Springer Science+Business Media New York 2014
Introduction Acute tumour lysis syndrome (ATLS) is one of the lifethreatening complications of chemotherapy for cancers. It has typical biochemical finding of hyperuricaemia, acute renal failure, hyperkalaemia, hypophosphataemia and hypocalcaemia. These findings are caused by disintegration of tumour cells and subsequent release of their content in to the blood [1]. ATLS is usually seen in tumours with heavy cell turnover and large burden. It is because of this reason, ATLS is primarily seen in cancers of the blood but it has also been more increasingly
Key Messages ATLS can also develop in the solid tumour and carries high mortality. ATLS should be suspected in all patients with history of cancers who present to clinicians with acute renal failure accompanied by hyperuricaemia. H. Goyal (*) Department of Internal Medicine, Mercer University School of Medicine, 707 Pine St,, Macon, GA 31201, USA e-mail: [email protected] H. Sawhney : S. Bekara : U. Singla Department of Internal Medicine, Wyckoff Heights Medical Center, 374 Stockholm St, Brooklyn, NY 11237, USA H. Sawhney e-mail: [email protected] S. Bekara e-mail: [email protected] U. Singla e-mail: [email protected]
recognized in solid tumours. Recently, ATLS has been described in relation to cancers of the colon [2], gall bladder [3], biliary tract [4], skin [5] and breast [6]. Here, we describe an exceedingly rare case of spontaneous ATLS in a patient with gastric adenocarcinoma. To our knowledge, only one case of spontaneous ATLS has been described previously in literature with adenocarcinoma of the stomach which was reported more than a decade ago [7].
Case History A 51-year-old man came to our emergency room with complaints of generalized weakness, severe nausea and vomiting for 2 days. He also complained of decreased urination for the same duration. He was diagnosed with poorly differentiated adenocarcinoma of the stomach about 9 months ago. Since then, the patient was receiving chemotherapy with Cisplatin, Docetaxel and 5-Fluorouracil. His last chemotherapy was about 2 months before this presentation. Physical examination revealed mild epigastric tenderness and sluggish bowel sounds. Pertinent laboratory findings are summarized in Table 1. Gastric outlet obstruction was ruled out by history and physical examination. All above laboratory findings were highly suggestive of ATLS. The patient’s spot urine uric acid-to-urine creatinine ratio was 1.2 which was consistent with uric acid nephropathy. The patient was started on aggressive intravenous hydration and allopurinol. A CT scan of the abdomen revealed a large
J Gastrointest Canc Table 1 Biochemical data of the patient at the time of presentation Laboratorial data
Results
Sodium Potassium Magnesium Calcium Blood urea nitrogen Creatinine Lactate dehydrogenase Phosphorus Haemoglobin Haematocrit Uric acid Creatine phosphokinase
146 mmol/L 5.3 3.6 8.9 193 mg/dL 11.4 568 IU/L 15.2 12.5 37.2 27.9 478 IU/L
mmol/L mg/dL mg/dL mg/dL mg/dL g/dL g/dL g/dL
Fig. 3 Rectal wall thickening
metastatic mass in the left lobe of the liver (Fig. 1), multiple enlarged mesenteric lymph nodes (Fig. 2), gastric and colonic wall thickening (Fig. 3) and metastatic lesions in the L-4 vertebra (Fig. 4) and right adrenal gland which were suggestive of a large tumour burden. The patient’s renal failure continued to worsen and urine output did not improve with the symptomatic treatment. Recombinant urate oxidase, rasburicase, could not be used for this patient due to its unavailability in our facility at that time. The patient was started on renal replacement therapy via a temporary central catheter, and after two haemodialysis sessions, his renal functions started to improve (Fig. 5). Later, the patient responded well to symptomatic treatment with improvement in his general condition and complete resolution of electrolyte imbalance in 8 days.
Fig. 1 Large metastatic mass in the left lobe of the liver and gastric wall thickening
Fig. 2 Multiple enlarged mesenteric lymph nodes
Fig. 4 Metastatic lesion in L4 vertebra
J Gastrointest Canc
30 Values (mg/dL)
Fig. 5 Trend of uric acid and creatinine levels of the patient during the hospital stay
25 20
Creatinine
15
Uric Acid
10 5 0 1
2
3
4
5
6
7
8
No. of Days
Discussion ATLS is an oncologic emergency which usually occurs in highly proliferative cancers especially chemosensitive haematological malignancies. It occurs usually immediately after therapy of cancers but can also occur spontaneously (without management of cancer). It can occur after any type of therapy for cancers including chemotherapy, steroids and transarterial chemoembolization. Recently, ATLS is being more recognized in solid tumours which could be due to the availability of more efficacious treatment for these cancers and/or due to increased vigilance for ATLS. Moreover, it has been suggested that mortality in patients with ATLS in solid malignancies is very high, reaching up to 35 % [8]. In solid tumours, ATLS often occurs after some days of initiation of treatment usually when the patient has left the hospital. This
could be a cause of increased mortality in these patients. Interestingly, all the reported patients with ATLS in gastric cancer had favourable outcome. The association of gastric adenocarcinoma and ATLS is very rare. On review of PubMed with search words ‘acute tumour lysis syndrome and gastric cancer’ and ‘tumour lysis and gastric carcinoma’, only three cases of ATLS associated with adenocarcinoma of the stomach were found. Only one of these reported cases had spontaneous ATLS. The characteristics of all these cases are summarized in Table 2. This case illustrates the need for increased vigilance for ATLS even in solid tumours. It appears that patients with large tumour size and advanced cancer stages may be at increased risk of ATLS. It is suggested that patients with decreased baseline renal functions and deranged baseline electrolytes and uric acid levels are at increased risk of ATLS. We suggest that ATLS should be suspected in all patients with history of
Table 2 Characteristics of patients with ATLS and gastric adenocarcinoma previously described in literature Authors
Woo et al. [7] Han et al. [9] Vodopivec et al. [10] Kobayashi et al. [11] Present case
Patient’s characteristics Age
Sex
Chemotherapy
Treatment outcome
36 38 57 69 51
M M M M M
None Cisplatin and Capecitabine Oxaliplatin, Leucovirin, Floxuridine and Docetaxel S-1 and Cisplatin None (2 months earlier he received Cisplatin, Docetaxel, 5-Fluorouracil)
Improved Improved Improved Improved Improved
J Gastrointest Canc
cancers who present to clinicians with acute renal failure accompanied by hyperuricaemia.
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Howard SC, Jones DP, Pui CH. The tumour lysis syndrome. N Engl J Med. 2011;364(19):1844–54. 2. Kim HD, Ha KS, Woo IS, Jung YH, Han CW, Kim TJ. Tumor lysis syndrome in a patient with metastatic colon cancer after treatment with 5-Fluorouracil/Leucovorin and Oxaliplatin: case report and literature review. Cancer Res Treat. 2014;46(2):204–7. 3. Duff DJ, Haddadin S, Freter C, Papageorgiou C. Gemcitabine and cisplatin-induced tumor lysis syndrome in a patient with gallbladder carcinoma: a case report. Oncol Lett. 2013;5(4):1237–9. 4. Ali AM, Barbaryan A, Zdunek T, Khan M, Voore P, Mirrakhimov AE. Spontaneous tumor lysis syndrome in a patient with cholangiocarcinoma. J Gastrointest Oncol. 2014;5(2):E46–9.
5. Grenader T, Shavit L. Tumor lysis syndrome in a patient with merkel cell carcinoma and provoked pathologic sequence of acute kidney injury, reduced clearance of carboplatin and fatal pancytopenia. Onkologie. 2011;34(11):626–9. 6. Goyal H, Sawhney H, Singh J. Spontaneous fatal recurrent tumor lysis syndrome in ductal breast carcinoma. Commun Oncol. 2012;9: 136–7. 7. Woo IS, Kim JS, Park MJ, Lee MS, Cheon RW, Chang HM, et al. Spontaneous acute tumor lysis syndrome with advanced gastric cancer. J Korean Med Sci. 2001;16(1):115–8. 8. Tosi P, Barosi G, Lazzaro C, Liso V, Marchetti M, Morra E, et al. Consensus conference on the management of tumor lysis syndrome. Haematologica. 2008;93(12):1877–85. 9. Han HS, Park SR, Kim SY, Park YI, Lee JS, Kook MC, et al. Tumor lysis syndrome after capecitabine plus cisplatin treatment in advanced gastric cancer. J Clin Oncol. 2008;26(6): 1006–8. 10. Vodopivec DM, Rubio JE, Fornoni A, Lenz O. An unusual presentation of tumor lysis syndrome in a patient with advanced gastric adenocarcinoma: case report and literature review. Case Rep Med. 2012;2012:12. Article ID 468452. 11. Kobayashi T, Kuwai T, Yamamoto S, et al. Acute tumor lysis syndrome in the setting of advanced gastric cancer. Nihon Shokakibyo Gakkai Zasshi. 2012;109(8):1372–8.
CASE REPORT
Spontaneous Acute Tumour Lysis Syndrome in Gastric Adenocarcinoma: A Case Report and Literature Review Hemant Goyal & Harinder Sawhney & Swetha Bekara & Umesh Singla
# Springer Science+Business Media New York 2014
Introduction Acute tumour lysis syndrome (ATLS) is one of the lifethreatening complications of chemotherapy for cancers. It has typical biochemical finding of hyperuricaemia, acute renal failure, hyperkalaemia, hypophosphataemia and hypocalcaemia. These findings are caused by disintegration of tumour cells and subsequent release of their content in to the blood [1]. ATLS is usually seen in tumours with heavy cell turnover and large burden. It is because of this reason, ATLS is primarily seen in cancers of the blood but it has also been more increasingly
Key Messages ATLS can also develop in the solid tumour and carries high mortality. ATLS should be suspected in all patients with history of cancers who present to clinicians with acute renal failure accompanied by hyperuricaemia. H. Goyal (*) Department of Internal Medicine, Mercer University School of Medicine, 707 Pine St,, Macon, GA 31201, USA e-mail: [email protected] H. Sawhney : S. Bekara : U. Singla Department of Internal Medicine, Wyckoff Heights Medical Center, 374 Stockholm St, Brooklyn, NY 11237, USA H. Sawhney e-mail: [email protected] S. Bekara e-mail: [email protected] U. Singla e-mail: [email protected]
recognized in solid tumours. Recently, ATLS has been described in relation to cancers of the colon [2], gall bladder [3], biliary tract [4], skin [5] and breast [6]. Here, we describe an exceedingly rare case of spontaneous ATLS in a patient with gastric adenocarcinoma. To our knowledge, only one case of spontaneous ATLS has been described previously in literature with adenocarcinoma of the stomach which was reported more than a decade ago [7].
Case History A 51-year-old man came to our emergency room with complaints of generalized weakness, severe nausea and vomiting for 2 days. He also complained of decreased urination for the same duration. He was diagnosed with poorly differentiated adenocarcinoma of the stomach about 9 months ago. Since then, the patient was receiving chemotherapy with Cisplatin, Docetaxel and 5-Fluorouracil. His last chemotherapy was about 2 months before this presentation. Physical examination revealed mild epigastric tenderness and sluggish bowel sounds. Pertinent laboratory findings are summarized in Table 1. Gastric outlet obstruction was ruled out by history and physical examination. All above laboratory findings were highly suggestive of ATLS. The patient’s spot urine uric acid-to-urine creatinine ratio was 1.2 which was consistent with uric acid nephropathy. The patient was started on aggressive intravenous hydration and allopurinol. A CT scan of the abdomen revealed a large
J Gastrointest Canc Table 1 Biochemical data of the patient at the time of presentation Laboratorial data
Results
Sodium Potassium Magnesium Calcium Blood urea nitrogen Creatinine Lactate dehydrogenase Phosphorus Haemoglobin Haematocrit Uric acid Creatine phosphokinase
146 mmol/L 5.3 3.6 8.9 193 mg/dL 11.4 568 IU/L 15.2 12.5 37.2 27.9 478 IU/L
mmol/L mg/dL mg/dL mg/dL mg/dL g/dL g/dL g/dL
Fig. 3 Rectal wall thickening
metastatic mass in the left lobe of the liver (Fig. 1), multiple enlarged mesenteric lymph nodes (Fig. 2), gastric and colonic wall thickening (Fig. 3) and metastatic lesions in the L-4 vertebra (Fig. 4) and right adrenal gland which were suggestive of a large tumour burden. The patient’s renal failure continued to worsen and urine output did not improve with the symptomatic treatment. Recombinant urate oxidase, rasburicase, could not be used for this patient due to its unavailability in our facility at that time. The patient was started on renal replacement therapy via a temporary central catheter, and after two haemodialysis sessions, his renal functions started to improve (Fig. 5). Later, the patient responded well to symptomatic treatment with improvement in his general condition and complete resolution of electrolyte imbalance in 8 days.
Fig. 1 Large metastatic mass in the left lobe of the liver and gastric wall thickening
Fig. 2 Multiple enlarged mesenteric lymph nodes
Fig. 4 Metastatic lesion in L4 vertebra
J Gastrointest Canc
30 Values (mg/dL)
Fig. 5 Trend of uric acid and creatinine levels of the patient during the hospital stay
25 20
Creatinine
15
Uric Acid
10 5 0 1
2
3
4
5
6
7
8
No. of Days
Discussion ATLS is an oncologic emergency which usually occurs in highly proliferative cancers especially chemosensitive haematological malignancies. It occurs usually immediately after therapy of cancers but can also occur spontaneously (without management of cancer). It can occur after any type of therapy for cancers including chemotherapy, steroids and transarterial chemoembolization. Recently, ATLS is being more recognized in solid tumours which could be due to the availability of more efficacious treatment for these cancers and/or due to increased vigilance for ATLS. Moreover, it has been suggested that mortality in patients with ATLS in solid malignancies is very high, reaching up to 35 % [8]. In solid tumours, ATLS often occurs after some days of initiation of treatment usually when the patient has left the hospital. This
could be a cause of increased mortality in these patients. Interestingly, all the reported patients with ATLS in gastric cancer had favourable outcome. The association of gastric adenocarcinoma and ATLS is very rare. On review of PubMed with search words ‘acute tumour lysis syndrome and gastric cancer’ and ‘tumour lysis and gastric carcinoma’, only three cases of ATLS associated with adenocarcinoma of the stomach were found. Only one of these reported cases had spontaneous ATLS. The characteristics of all these cases are summarized in Table 2. This case illustrates the need for increased vigilance for ATLS even in solid tumours. It appears that patients with large tumour size and advanced cancer stages may be at increased risk of ATLS. It is suggested that patients with decreased baseline renal functions and deranged baseline electrolytes and uric acid levels are at increased risk of ATLS. We suggest that ATLS should be suspected in all patients with history of
Table 2 Characteristics of patients with ATLS and gastric adenocarcinoma previously described in literature Authors
Woo et al. [7] Han et al. [9] Vodopivec et al. [10] Kobayashi et al. [11] Present case
Patient’s characteristics Age
Sex
Chemotherapy
Treatment outcome
36 38 57 69 51
M M M M M
None Cisplatin and Capecitabine Oxaliplatin, Leucovirin, Floxuridine and Docetaxel S-1 and Cisplatin None (2 months earlier he received Cisplatin, Docetaxel, 5-Fluorouracil)
Improved Improved Improved Improved Improved
J Gastrointest Canc
cancers who present to clinicians with acute renal failure accompanied by hyperuricaemia.
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Howard SC, Jones DP, Pui CH. The tumour lysis syndrome. N Engl J Med. 2011;364(19):1844–54. 2. Kim HD, Ha KS, Woo IS, Jung YH, Han CW, Kim TJ. Tumor lysis syndrome in a patient with metastatic colon cancer after treatment with 5-Fluorouracil/Leucovorin and Oxaliplatin: case report and literature review. Cancer Res Treat. 2014;46(2):204–7. 3. Duff DJ, Haddadin S, Freter C, Papageorgiou C. Gemcitabine and cisplatin-induced tumor lysis syndrome in a patient with gallbladder carcinoma: a case report. Oncol Lett. 2013;5(4):1237–9. 4. Ali AM, Barbaryan A, Zdunek T, Khan M, Voore P, Mirrakhimov AE. Spontaneous tumor lysis syndrome in a patient with cholangiocarcinoma. J Gastrointest Oncol. 2014;5(2):E46–9.
5. Grenader T, Shavit L. Tumor lysis syndrome in a patient with merkel cell carcinoma and provoked pathologic sequence of acute kidney injury, reduced clearance of carboplatin and fatal pancytopenia. Onkologie. 2011;34(11):626–9. 6. Goyal H, Sawhney H, Singh J. Spontaneous fatal recurrent tumor lysis syndrome in ductal breast carcinoma. Commun Oncol. 2012;9: 136–7. 7. Woo IS, Kim JS, Park MJ, Lee MS, Cheon RW, Chang HM, et al. Spontaneous acute tumor lysis syndrome with advanced gastric cancer. J Korean Med Sci. 2001;16(1):115–8. 8. Tosi P, Barosi G, Lazzaro C, Liso V, Marchetti M, Morra E, et al. Consensus conference on the management of tumor lysis syndrome. Haematologica. 2008;93(12):1877–85. 9. Han HS, Park SR, Kim SY, Park YI, Lee JS, Kook MC, et al. Tumor lysis syndrome after capecitabine plus cisplatin treatment in advanced gastric cancer. J Clin Oncol. 2008;26(6): 1006–8. 10. Vodopivec DM, Rubio JE, Fornoni A, Lenz O. An unusual presentation of tumor lysis syndrome in a patient with advanced gastric adenocarcinoma: case report and literature review. Case Rep Med. 2012;2012:12. Article ID 468452. 11. Kobayashi T, Kuwai T, Yamamoto S, et al. Acute tumor lysis syndrome in the setting of advanced gastric cancer. Nihon Shokakibyo Gakkai Zasshi. 2012;109(8):1372–8.
