A Case of Tumor Lysis Syndrome in Breast Cancer
Gwen Ho¹, MD and Helen Chew², MD
¹Department of Internal Medicine, ² Department of Hematology-Oncology
University of California, Davis Medical Center, Sacramento, CA
Introduction
Discussion
Labs and Imaging
Tumor lysis is a well-characterized syndrome observed after
chemotherapy in patients with acute leukemias and lymphomas, but
rarely in solid tumors. Review of the literature shows several similar
cases in patients with breast cancer, lung cancer and disseminated
seminoma undergoing chemotherapy. Common risk factors include
extensive bulky disease including hepatic metastases and rapid
growth.
Tumor lysis syndrome is the most common oncologic
emergency in hematologic malignancies, including aggressive
lymphomas, but is rarely described in solid tumors. It is
characterized
by
hyperuricemia,
hyperkalemia,
hyperphosphatemia and hypocalcemia leading to renal failure,
arrhythmias and even death. We report a case of tumor lysis
syndrome in a woman with metastatic breast cancer
Case Presentation
KF was initially diagnosed in 2004 with stage 1 ER/PR negative
and HER-2/neu negative left-sided breast cancer. She was treated
with lumpectomy, sentinel lymph node biopsy, adjuvant
chemotherapy and radiation.
She was diagnosed with a second left breast cancer in March
2010, which was triple negative and had a Ki-67 index of 90%.
She underwent bilateral mastectomies in May 2010. Imaging did
not reveal any metastases.
The patient deferred adjuvant chemotherapy until October 2010,
when she had palpable axillary adenopathy, confirmed by
imaging.
She
completed
dose-dense
doxorubicin,
cyclophosphamide and paclitaxel in February 2011, with a
significant clinical response, and went on to axillary lymph node
dissection in March 2011.
By April 2011, she complained of increasing abdominal and back
pain. CT scans on 4/13/11 showed new metastases to her liver
and bones with periportal and retroperitoneal lymphadenopathy.
She was admitted on 4/20/11 for abdominal pain, attributed to
metastatic disease. Chemotherapy with carboplatin and
gemcitabine was initiated on 4/21/11.
CT abdomen - February 2011
Calcium
Potassium
Phosphorus
Uric acid
Creatinine
CT abdomen - April 2011
Hospital Day 3
Hospital Day 6
(post-treatment)
6.2
5.4
9
15
2.0
7.2
3.8
3
2
1.4
While these case reports indicate that tumor lysis can occur in solid
tumors, it is still relatively rare. In those patients with large tumor
burdens and rapidly progressive disease, consideration should be
made on monitoring for tumor lysis while these patients undergo
chemotherapy in order to prevent the effects of renal failure and
metabolic disturbances. This includes regular measurements of
renal function, electrolytes, uric acid and lactate dehydrogenase.
Conclusion
While tumor lysis in solid tumors is rare, monitoring for tumor lysis
should be considered in patients undergoing chemotherapy with
extensive, rapidly progressive disease.
Hospital course
References
On HD#2, one day following initiation of chemotherapy, patient had
worsening renal function, initially presumed pre-renal. She was given
aggressive fluid resuscitation. On HD#3, she became tachypneic and altered
and transferred to the ICU. A diagnosis of tumor lysis syndrome was made,
based on the labs above, including corrected anion gap of 17, LDH 2239,
lactic acid 2, BUN 73. Rasburicase and allopurinol were started. She did not
require dialysis. On HD#6, she had improvement in her symptoms and
electrolytes. She was discharged home on HD #13.
Barton, J. C. (1989). "Tumor lysis syndrome in nonhematopoietic neoplasms." Cancer 64(3): 738-740.
Drakos, P., J. Bar-Ziv, et al. (1994). "Tumor lysis syndrome in nonhematologic malignancies. Report of a
case and review of the literature." Am J Clin Oncol 17(6): 502-505.
Howard, S. C., D. P. Jones, et al. (2011). "The tumor lysis syndrome." N Engl J Med 364(19): 1844-1854.
Hussein, A. M. and L. G. Feun (1990). "Tumor lysis syndrome after induction chemotherapy in small-cell
lung carcinoma." Am J Clin Oncol 13(1): 10-13.
Mott, F. E., A. Esana, et al. (2005). "Tumor lysis syndrome in solid tumors." Support Cancer Ther 2(3): 188191.
Sklarin, N. T. and M. Markham (1995). "Spontaneous recurrent tumor lysis syndrome in breast cancer." Am J
Clin Oncol 18(1): 71-73.
Stark, M. E., M. C. Dyer, et al. (1987). "Fatal acute tumor lysis syndrome with metastatic breast carcinoma."
Cancer 60(4): 762-764.
Vogelzang, N. J., R. A. Nelimark, et al. (1983). "Tumor lysis syndrome after induction chemotherapy of smallcell bronchogenic carcinoma." JAMA 249(4): 513-514.