Acute tumor lysis syndrome induced by high-dose corticosteroids in a patient with chronic lymphatic leukemia

Abstract

Acute tumor lysis syndrome (TLS) has been reported in hematological malignancies, such as aggressive non-Hodgkin's lymphoma, acute lymphoblastic leukemia, and rarely, in other malignancies (solid tumors) in association with the administration of cytotoxic therapy. We report a case of a patient with chronic lymphatic leukemia (CLL) who developed autoimmune hemolytic anemia treated by high dose corticosteroids and, following this treatment, developed acute tumor lysis syndrome. Only one similar case has been reported recently. Clinicians should be aware that corticosteroids alone may produce this potentially life-threatening complication.

Flavopiridol administered using a pharmacologically derived schedule is associated with marked clinical efficacy in refractory, genetically high-risk chronic lymphocytic leukemia

“…Remarkably, the dose-limiting toxicity in this trial was hyperacute TLS, a toxicity only rarely observed in CLL. [34][35][36][37][38] With experience derived from this trial, we were able to identify that patients at highest risk for this toxicity have elevated leukocyte counts greater than 200 ϫ 10 9 / L. Exclusion of patients with counts greater than 200 ϫ 10 9 /L has provided for safe administration relative to hyperacute TLS in the next 17 patients treated using this same stepped-up dosing on days 1 and 8 of therapy. 39 The frequency of responses in patients with genetically high-risk and fludarabine-refractory CLL indicates substantial potential for this agent for both this patient group as well as for the initial treatment of CLL as part of combination therapies and as a single agent.…”

Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus

“…Returning to the two case reports discussed above, in the dialysis patient with DLBCL (Lin et al , 2009) the risk classification of this patient would be moved from intermediate to high risk of TLS according to this new risk classification system due to increased LDH levels, renal dysfunction and the presence of bulky disease, while the CLL patient (Vaisban et al , 2001) would be elevated from low risk to intermediate risk of TLS due to the presence of pre‐existing asotemia. These two examples demonstrate the broad applicability of this new risk classification model and its ability to identify TLS risk even in unusual settings, such as DLBCL, where it is not immediately considered.…”

“…TLS may also occur in other tumour types, especially tumours sensitive to cytotoxic treatment, that have a high proliferative rate or have a large tumuor size or burden (Coiffier et al , 2008). Unexpected cases of TLS where a high TLS risk was not immediately evident and for which appropriate risk assessment and management could make the difference between life and death have also been reported (Kalemkerian et al , 1997; Vaisban et al , 2001; Francescone et al , 2009; Lin et al , 2009). For example, an adult patient with end‐stage renal disease and diffuse large B‐cell lymphoma (DLBCL) developed acute TLS after receiving low dose COP chemotherapy (cyclophosphamide, vincristine and dexamethasone) and allopurinol (Lin et al , 2009).…”

“…A computed tomography scan revealed a retroperitoneal mass (8·5 × 9·5 cm 2 ) while laboratory values on presentation included a creatinine level of 566 μmol/l and a lactate dehydrogenase (LDH) level of 523 u/l. In another case, an adult patient with chronic lymphocytic leukaemia (CLL) and pre‐existing asotemia developed acute TLS and renal failure after initiation of high‐dose corticosteroid therapy (Vaisban et al , 2001). Both of these cases highlight that overall TLS risk derives from the collective contribution of several individual risk factors and underline the critical need for a risk model that integrates them in order to identify high TLS risk, even in unusual settings.…”

Recurrent chemotherapy‐induced tumor lysis syndrome (TLS) with renal failure in a patient with chronic lymphocytic leukemia – successful treatment and prevention of TLS with low‐dose rasburicase

“…Tumor lysis syndrome in chronic lymphocytic leukemia (CLL) is rare, it has been observed after 2‐chlorodeoxyadenosine (3, 4), fludarabine (5, 6), anti‐CD20 monoclonal antibody (7, 8) and even after corticosteroid treatment (9).…”