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A New Challenging Strategy in the Prevention and Management of Tumor Lysis Syndrome in Patients with Chemo-Sensitive Hematological Malignancies

A New Challenging Strategy in the Prevention and Management of Tumor Lysis Syndrome in Patients... Hindawi Case Reports in Oncological Medicine Volume 2019, Article ID 3740547, 3 pages https://doi.org/10.1155/2019/3740547 Case Report A New Challenging Strategy in the Prevention and Management of Tumor Lysis Syndrome in Patients with Chemo-Sensitive Hematological Malignancies 1 1 1 2 Ammar ELJack , Mohamad El Abdallah, Kadhim Al-Banaa, Kashif Chaudhry, and Faisal Musa Department of Internal Medicine, Beaumont Hospital-Dearborn, 18101 Oakwood, Dearborn, MI 48124, USA Department of Nephrology, Beaumont Hospital-Dearborn, Dearborn, MI, USA Department of Hematology and Oncology, Beaumont Hospital-Dearborn, Dearborn, MI, USA Correspondence should be addressed to Ammar ELJack; ammar.eljack@beaumont.org Received 1 November 2018; Revised 6 March 2019; Accepted 23 April 2019; Published 19 May 2019 Academic Editor: Peter F. Lenehan Copyright © 2019 Ammar ELJack et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Tumor lysis syndrome (TLS) is a metabolic derangement that results from rapid destruction of cells. It happens frequently in cancers receiving chemotherapy, particularly hematological malignancies. It can lead to death in severe cases. Tumor lysis syndrome that leads to acute renal failure requiring dialysis and/or ICU admission can be associated with a higher rate of complications and mortality. Case Report. We present a 24-year-old male patient with Burkitt’s lymphoma. After receiving one cycle therapy, he developed severe kidney injury from TLS. We initiated renal replacement therapy soon after his admission to the ICU, with marked response to therapy. This led to early discharge from the ICU. Conclusion. Early initiation of renal replacement therapy after TLS-AKI can improve the severity of AKI and hasten recovery and prevent complications. This can lead to earlier discharge from the hospital and better outcomes. 1. Introduction Acute kidney injury (AKI) may frequently complicate TLS. It is caused by precipitation of uric acid, calcium phos- phate, or hypoxanthine in the renal tubules [3]. It may lead to Tumor lysis syndrome (TLS) is a serious complication of renal failure requiring renal replacement therapy (RRT) in its chemotherapy in rapidly progressive cancer. It presents clinically with nausea, vomiting, fatigue, acute kidney most severe forms. injury, seizure, arrhythmia, and even death. It is caused by the release of electrolytes from the damaged cells. Charac- 2. Case Scenario teristic electrolyte disturbances include hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia [1]. A 24-year-old male with no significant past medical his- The National Comprehensive Cancer Network (NCCN) tory presented to ED with gradually worsening abdominal guidelines recommended prophylaxis and treatment with pain for one month. His symptoms were associated with aggressive hydration and control of hyperuricemia with anorexia, black tarry stools, intermittent fever, sweating, vomiting, dizziness, and significant unintentional weight allopurinol (xanthine oxidase inhibitor) 2-3 days prior to chemotherapy or rasburicase (urate oxidase) which is highly loss (40 lbs in 3 months). On admission, his vital signs effective in prevention and treatment of TLS. It is indicated were stable. He was anxious and clammy, and his physical for high-risk patient, patient with adequate hydration not exam was significant for splenomegaly. Initial blood work possible to achieve, urgent therapy in high-bulk patient, showed leukocytosis with a white cell count of 33.9 and acute kidney injury [2]. K/Ul, hemoglobin was 15.3 g/dl, platelet count was 67 2 Case Reports in Oncological Medicine (a) (b) Figure 1: CT scan of the abdomen ((a) axial section, showed large 10 × 10 cm ileocolic mass, lymphadenopathy at the right colic area, and splenomegaly; (b) horizontal section). (a) (b) Figure 2: (a) Bone marrow biopsy with 400x H&E stain showed diffuse infiltrate and characterized by medium-to-large cells with irregular nuclear contour, prominent nucleoli, and cytoplasmic vacuoles. Brisk mitosis identified. (b) Colon biopsy with 400x H&E stain showed intermediate-sized lymphoid cells with scattered histiocytes imparting a “starry sky” pattern. DA EPOCH-R (dose-adjusted etoposide, prednisone, vin- K/Ul with blast cells of 30%. The liver panel showed aspartate aminotransferase (AST) of 161 IU/l, alanine ami- cristine, cyclophosphamide, doxorubicin, and rituximab), notransferase (ALT) of 65 IU/l, and alkaline phosphatase and prophylactic intrathecal chemotherapy (methotrexate, (ALP) of 64.3 IU/l. Total bilirubin was 0.9 mg/dl. Lactate cytarabine, and hydrocortisone). On day 2 of admission, dehydrogenase (LDH) was 6000 U/l, and uric acid was the patient developed TLS-AKI. His glomerular filtration rate (GFR) dropped to 22 ml/min/1.73 m 11.3 mg/dl. Urea was 14 mg/dl, and serum creatinine and serum creatinine was 1.24 mg/dl. Na was 139 mmol/l, K was 3.9 mmol/l, increased to 4 mg/dl (Figure 3). Treatment was started with aggressive hydration, ras- and Ca was 9.6 mmol/l. An abdominal CT scan showed large ileocolic mass with enlarged lymphadenopathy at the right buricase, and allopurinol. On day 5, all of the previous measures failed, and his kidney functions were deterio- colic area (Figure 1). rated, so renal replacement therapy (RRT) was initiated Peripheral smear showed immature cells with increase blast suggestive of acute leukemia. Biopsy of the colonic and continued for a total of 14 days. He responded well to therapy and was discharged from the hospital after 25 mass showed lymphoma. Flow cytometry confirmed the diagnosis of Burkitt’s lymphoma. CT head, neck, and tho- days of management with recommendations for outpatient follow-up. rax revealed no other lymph node involvement (Figure 2). The patient was diagnosed with stage IV Burkitt’s lym- phoma with leukemic phase. Treatment was initiated with 3. Discussion R hyper-CVAD (hyper-fractionated cyclophosphamide, vin- cristine, doxorubicin, and dexamethasone); he received one The overall incidence of TLS was reported at 4.4% in cycle of part A, then switched to another treatment regimen two large multicenter studies of non-Hodgkin lymphoma Case Reports in Oncological Medicine 3 Electrolyte disturbance expert TLS panel consensus,” British Journal of Haematology, vol. 149, no. 4, pp. 578–586, 2010. [2] N. L. Bartlett, “B-cell lymphomas,” 2018, https://www.nccn .org/professionals/physician_gls/pdf/b-cell.pdf. [3] F. Locatelli and F. Rossi, “Incidence and pathogenesis of tumor lysis syndrome,” in Hyperuricemic Syndromes: Pathophysiology and Therapy, C. Ronco and F. Rodeghiero, Eds., vol. 147 of Contributions to Nephrology, , pp. 61–68, Karger, 2004. [4] W. Wossmann, M. Schrappe, U. Meyer, M. Zimmermann, and A. Reiter, “Incidence of tumor lysis syndrome in children with Uric acid Phosphrus Calcium advanced stage Burkitt’s lymphoma/leukemia before and after Potassium introduction of prophylactic use of urate oxidase,” Annals of Figure 3: Electrolyte disturbance in TLS patient over the days since Hematology, vol. 82, no. 3, pp. 160–165, 2003. hospital admission. [5] P. S. Garimella, P. Balakrishnan, N. R. Ammakkanavar et al., “Impact of dialysis requirement on outcomes in tumor lysis syndrome,” Nephrology, vol. 22, no. 1, pp. 85–88, 2017. (NHL). Of these, TLS occurred in 8.4% of the patients [6] M. Darmon, I. Guichard, F. Vincent, B. Schlemmer, and diagnosed with Burkitt’s lymphoma/leukemia or B-cell É. Azoulay, “Prognostic significance of acute renal injury in acute lymphocytic leukemia (B-ALL) [4]. acute tumor lysis syndrome,” Leukemia & Lymphoma, vol. 51, In a large retrospective study in the United States, the no. 2, pp. 221–227, 2009. nation-wide estimate of patients admitted with TLS was [7] E. Azoulay and B. Afessa, “The intensive care support of 22,785. 12.8% of them developed acute kidney injury patients with malignancy: do everything that can be done,” requiring dialysis (AKI-D) [5]. AKI-D patients have higher Intensive Care Medicine, vol. 32, no. 1, pp. 3–5, 2006. mortality (41.9% vs. 19.1%; P <0 01) and longer hospital stay than patients with AKI without dialysis requirement (19 vs. 14.9 days; P <0 01) [5]. In a single-center study at Saint- Louis University Hospital in France that included 63 patients, the adjusted mortality at hospital discharge was higher in patients with TLS who developed AKI (odds ratio: 10.41; 95% confidence interval: 2.01-19.17; P =0 005). Inter- estingly, RRT was performed in 17 patients without AKI and in 31 patients with TLS-induced AKI [6]. TLS-induced AKI may decrease the probability of getting a long-term remission of the malignancy; therefore, prevention of the development of AKI plays an essential role in the management of TLS, and consequently, primary malignancy outcome [6, 7]. In patients with hematological malignancies who require chemotherapy, anticipation and early recognition of TLS and intervention play crucial roles in the treatment and prevention of complications. Although RRT by self cannot prevent AKI from occurrence in a patient with TLS, we challenge that early initiation of RRT could play a pivotal role in preventing complications associated with TLS, even in early stages of AKI. Further clinical trials are needed to evaluate early intervention using RRT to assess prognosis as well as mortality and morbidity in patients with chemo-sensitive hematological malignancies who developed TLS. Conflicts of Interest The authors have declared that no conflict of interest exists. References [1] M. S. Cairo, B. Coiffier, A. Reiter, A. Younes, and on behalf of the TLS Expert Panel, “Recommendations for the evalua- tion of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an mg/dl Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 14 MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Hindawi Publishing Corporation Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 http://www www.hindawi.com .hindawi.com V Volume 2018 olume 2013 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 International Journal of Journal of Immunology Research Endocrinology Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Submit your manuscripts at www.hindawi.com BioMed PPAR Research Research International Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2013 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

A New Challenging Strategy in the Prevention and Management of Tumor Lysis Syndrome in Patients with Chemo-Sensitive Hematological Malignancies

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Copyright © 2019 Ammar ELJack et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Case Reports in Oncological Medicine Volume 2019, Article ID 3740547, 3 pages https://doi.org/10.1155/2019/3740547 Case Report A New Challenging Strategy in the Prevention and Management of Tumor Lysis Syndrome in Patients with Chemo-Sensitive Hematological Malignancies 1 1 1 2 Ammar ELJack , Mohamad El Abdallah, Kadhim Al-Banaa, Kashif Chaudhry, and Faisal Musa Department of Internal Medicine, Beaumont Hospital-Dearborn, 18101 Oakwood, Dearborn, MI 48124, USA Department of Nephrology, Beaumont Hospital-Dearborn, Dearborn, MI, USA Department of Hematology and Oncology, Beaumont Hospital-Dearborn, Dearborn, MI, USA Correspondence should be addressed to Ammar ELJack; ammar.eljack@beaumont.org Received 1 November 2018; Revised 6 March 2019; Accepted 23 April 2019; Published 19 May 2019 Academic Editor: Peter F. Lenehan Copyright © 2019 Ammar ELJack et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Tumor lysis syndrome (TLS) is a metabolic derangement that results from rapid destruction of cells. It happens frequently in cancers receiving chemotherapy, particularly hematological malignancies. It can lead to death in severe cases. Tumor lysis syndrome that leads to acute renal failure requiring dialysis and/or ICU admission can be associated with a higher rate of complications and mortality. Case Report. We present a 24-year-old male patient with Burkitt’s lymphoma. After receiving one cycle therapy, he developed severe kidney injury from TLS. We initiated renal replacement therapy soon after his admission to the ICU, with marked response to therapy. This led to early discharge from the ICU. Conclusion. Early initiation of renal replacement therapy after TLS-AKI can improve the severity of AKI and hasten recovery and prevent complications. This can lead to earlier discharge from the hospital and better outcomes. 1. Introduction Acute kidney injury (AKI) may frequently complicate TLS. It is caused by precipitation of uric acid, calcium phos- phate, or hypoxanthine in the renal tubules [3]. It may lead to Tumor lysis syndrome (TLS) is a serious complication of renal failure requiring renal replacement therapy (RRT) in its chemotherapy in rapidly progressive cancer. It presents clinically with nausea, vomiting, fatigue, acute kidney most severe forms. injury, seizure, arrhythmia, and even death. It is caused by the release of electrolytes from the damaged cells. Charac- 2. Case Scenario teristic electrolyte disturbances include hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia [1]. A 24-year-old male with no significant past medical his- The National Comprehensive Cancer Network (NCCN) tory presented to ED with gradually worsening abdominal guidelines recommended prophylaxis and treatment with pain for one month. His symptoms were associated with aggressive hydration and control of hyperuricemia with anorexia, black tarry stools, intermittent fever, sweating, vomiting, dizziness, and significant unintentional weight allopurinol (xanthine oxidase inhibitor) 2-3 days prior to chemotherapy or rasburicase (urate oxidase) which is highly loss (40 lbs in 3 months). On admission, his vital signs effective in prevention and treatment of TLS. It is indicated were stable. He was anxious and clammy, and his physical for high-risk patient, patient with adequate hydration not exam was significant for splenomegaly. Initial blood work possible to achieve, urgent therapy in high-bulk patient, showed leukocytosis with a white cell count of 33.9 and acute kidney injury [2]. K/Ul, hemoglobin was 15.3 g/dl, platelet count was 67 2 Case Reports in Oncological Medicine (a) (b) Figure 1: CT scan of the abdomen ((a) axial section, showed large 10 × 10 cm ileocolic mass, lymphadenopathy at the right colic area, and splenomegaly; (b) horizontal section). (a) (b) Figure 2: (a) Bone marrow biopsy with 400x H&E stain showed diffuse infiltrate and characterized by medium-to-large cells with irregular nuclear contour, prominent nucleoli, and cytoplasmic vacuoles. Brisk mitosis identified. (b) Colon biopsy with 400x H&E stain showed intermediate-sized lymphoid cells with scattered histiocytes imparting a “starry sky” pattern. DA EPOCH-R (dose-adjusted etoposide, prednisone, vin- K/Ul with blast cells of 30%. The liver panel showed aspartate aminotransferase (AST) of 161 IU/l, alanine ami- cristine, cyclophosphamide, doxorubicin, and rituximab), notransferase (ALT) of 65 IU/l, and alkaline phosphatase and prophylactic intrathecal chemotherapy (methotrexate, (ALP) of 64.3 IU/l. Total bilirubin was 0.9 mg/dl. Lactate cytarabine, and hydrocortisone). On day 2 of admission, dehydrogenase (LDH) was 6000 U/l, and uric acid was the patient developed TLS-AKI. His glomerular filtration rate (GFR) dropped to 22 ml/min/1.73 m 11.3 mg/dl. Urea was 14 mg/dl, and serum creatinine and serum creatinine was 1.24 mg/dl. Na was 139 mmol/l, K was 3.9 mmol/l, increased to 4 mg/dl (Figure 3). Treatment was started with aggressive hydration, ras- and Ca was 9.6 mmol/l. An abdominal CT scan showed large ileocolic mass with enlarged lymphadenopathy at the right buricase, and allopurinol. On day 5, all of the previous measures failed, and his kidney functions were deterio- colic area (Figure 1). rated, so renal replacement therapy (RRT) was initiated Peripheral smear showed immature cells with increase blast suggestive of acute leukemia. Biopsy of the colonic and continued for a total of 14 days. He responded well to therapy and was discharged from the hospital after 25 mass showed lymphoma. Flow cytometry confirmed the diagnosis of Burkitt’s lymphoma. CT head, neck, and tho- days of management with recommendations for outpatient follow-up. rax revealed no other lymph node involvement (Figure 2). The patient was diagnosed with stage IV Burkitt’s lym- phoma with leukemic phase. Treatment was initiated with 3. Discussion R hyper-CVAD (hyper-fractionated cyclophosphamide, vin- cristine, doxorubicin, and dexamethasone); he received one The overall incidence of TLS was reported at 4.4% in cycle of part A, then switched to another treatment regimen two large multicenter studies of non-Hodgkin lymphoma Case Reports in Oncological Medicine 3 Electrolyte disturbance expert TLS panel consensus,” British Journal of Haematology, vol. 149, no. 4, pp. 578–586, 2010. [2] N. L. Bartlett, “B-cell lymphomas,” 2018, https://www.nccn .org/professionals/physician_gls/pdf/b-cell.pdf. [3] F. Locatelli and F. Rossi, “Incidence and pathogenesis of tumor lysis syndrome,” in Hyperuricemic Syndromes: Pathophysiology and Therapy, C. Ronco and F. Rodeghiero, Eds., vol. 147 of Contributions to Nephrology, , pp. 61–68, Karger, 2004. [4] W. Wossmann, M. Schrappe, U. Meyer, M. Zimmermann, and A. Reiter, “Incidence of tumor lysis syndrome in children with Uric acid Phosphrus Calcium advanced stage Burkitt’s lymphoma/leukemia before and after Potassium introduction of prophylactic use of urate oxidase,” Annals of Figure 3: Electrolyte disturbance in TLS patient over the days since Hematology, vol. 82, no. 3, pp. 160–165, 2003. hospital admission. [5] P. S. Garimella, P. Balakrishnan, N. R. Ammakkanavar et al., “Impact of dialysis requirement on outcomes in tumor lysis syndrome,” Nephrology, vol. 22, no. 1, pp. 85–88, 2017. (NHL). Of these, TLS occurred in 8.4% of the patients [6] M. Darmon, I. Guichard, F. Vincent, B. Schlemmer, and diagnosed with Burkitt’s lymphoma/leukemia or B-cell É. Azoulay, “Prognostic significance of acute renal injury in acute lymphocytic leukemia (B-ALL) [4]. acute tumor lysis syndrome,” Leukemia & Lymphoma, vol. 51, In a large retrospective study in the United States, the no. 2, pp. 221–227, 2009. nation-wide estimate of patients admitted with TLS was [7] E. Azoulay and B. Afessa, “The intensive care support of 22,785. 12.8% of them developed acute kidney injury patients with malignancy: do everything that can be done,” requiring dialysis (AKI-D) [5]. AKI-D patients have higher Intensive Care Medicine, vol. 32, no. 1, pp. 3–5, 2006. mortality (41.9% vs. 19.1%; P <0 01) and longer hospital stay than patients with AKI without dialysis requirement (19 vs. 14.9 days; P <0 01) [5]. In a single-center study at Saint- Louis University Hospital in France that included 63 patients, the adjusted mortality at hospital discharge was higher in patients with TLS who developed AKI (odds ratio: 10.41; 95% confidence interval: 2.01-19.17; P =0 005). Inter- estingly, RRT was performed in 17 patients without AKI and in 31 patients with TLS-induced AKI [6]. TLS-induced AKI may decrease the probability of getting a long-term remission of the malignancy; therefore, prevention of the development of AKI plays an essential role in the management of TLS, and consequently, primary malignancy outcome [6, 7]. In patients with hematological malignancies who require chemotherapy, anticipation and early recognition of TLS and intervention play crucial roles in the treatment and prevention of complications. Although RRT by self cannot prevent AKI from occurrence in a patient with TLS, we challenge that early initiation of RRT could play a pivotal role in preventing complications associated with TLS, even in early stages of AKI. Further clinical trials are needed to evaluate early intervention using RRT to assess prognosis as well as mortality and morbidity in patients with chemo-sensitive hematological malignancies who developed TLS. Conflicts of Interest The authors have declared that no conflict of interest exists. References [1] M. S. Cairo, B. Coiffier, A. Reiter, A. Younes, and on behalf of the TLS Expert Panel, “Recommendations for the evalua- tion of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an mg/dl Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 14 MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Hindawi Publishing Corporation Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 http://www www.hindawi.com .hindawi.com V Volume 2018 olume 2013 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 International Journal of Journal of Immunology Research Endocrinology Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Submit your manuscripts at www.hindawi.com BioMed PPAR Research Research International Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2013 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018

Journal

Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: May 19, 2019

References