Pembrolizumab‐axitinib‐induced tumor lysis syndrome in a patient with metastatic renal cancer

Abstract

Tumor lysis syndrome is uncommon in solid tumors but with the use of immunotherapy (checkpoint inhibitors) their incidence is increasing. Physicians need to take adequate precautions while treating patients with immunotherapy. The findings of our case report will help improve our current understanding of tumor lysis syndrome specially in solid tumors and will help in developing multidisciplinary treatment and prophylaxis strategies for this uncommon, but potentially fatal complication.

Immune Checkpoint Inhibitor–Associated Tumor Lysis Syndrome: A Real-World Pharmacovigilance Study

“…However, some metabolic disorders in the context of TLS including hyperkalemia and acute kidney injury were occasionally reported in association with pembrolizumab ( Langer et al, 2016 ; Goldberg et al, 2020 ; Middleton et al, 2020 ), avelumab ( Barlesi et al, 2018 ), and durvalumab uses ( Massard et al, 2016 ). Currently, just eight case reports of individuals developing TLS while receiving treatment with ICIs or co-chemotherapy have been reported in the PubMed database ( Masson Regnault et al, 2017 ; Fa’ak et al, 2019 ; Carrier et al, 2020 ; Magara et al, 2020 ; Narukawa et al, 2020 ; Shah et al, 2020 ; Sugimoto et al, 2020 ; Yen et al, 2020 ). All cases involved solid tumors—three cases of metastatic melanoma ( Masson Regnault et al, 2017 ; Magara et al, 2020 ; Sugimoto et al, 2020 ), three cases of genitourinary malignancies ( Fa’ak et al, 2019 ; Narukawa et al, 2020 ; Shah et al, 2020 ), one case of hepatocellular carcinoma ( Yen et al, 2020 ), and one case of metastatic triple-negative breast cancer ( Carrier et al, 2020 ).…”

“…Currently, just eight case reports of individuals developing TLS while receiving treatment with ICIs or co-chemotherapy have been reported in the PubMed database ( Masson Regnault et al, 2017 ; Fa’ak et al, 2019 ; Carrier et al, 2020 ; Magara et al, 2020 ; Narukawa et al, 2020 ; Shah et al, 2020 ; Sugimoto et al, 2020 ; Yen et al, 2020 ). All cases involved solid tumors—three cases of metastatic melanoma ( Masson Regnault et al, 2017 ; Magara et al, 2020 ; Sugimoto et al, 2020 ), three cases of genitourinary malignancies ( Fa’ak et al, 2019 ; Narukawa et al, 2020 ; Shah et al, 2020 ), one case of hepatocellular carcinoma ( Yen et al, 2020 ), and one case of metastatic triple-negative breast cancer ( Carrier et al, 2020 ). These patients were treated with atezolizumab, nivolumab, or ipilimumab monotherapy ( Masson Regnault et al, 2017 ; Fa’ak et al, 2019 ; Sugimoto et al, 2020 ); combined therapy of nivolumab plus ipilimumab ( Magara et al, 2020 ); co-chemotherapy with nanoparticle albumin-bound-paclitaxel and atezolizumab ( Carrier et al, 2020 ); nivolumab plus sorafenib ( Yen et al, 2020 ); pazopanib after nivolumab ( Narukawa et al, 2020 ); or pembrolizumab plus axitinib ( Shah et al, 2020 ).…”

“…TLS onset was between 5 and 10 days after the initiation of therapy, with various clinical symptoms such as weakness, fatigue, nausea, vomiting, diarrhea, and abdominal pain. Five out of eight patients died within 3–22 days after hospital admission ( Masson Regnault et al, 2017 ; Narukawa et al, 2020 ; Shah et al, 2020 ; Sugimoto et al, 2020 ; Yen et al, 2020 ) and one after being discharged for home hospice ( Fa’ak et al, 2019 ).…”

Electrolyte and Acid-Base Disorders Associated with Cancer Immunotherapy

“…Tumor lysis syndrome, marked by hyperphosphatemia and other elements in the Cairo–Bishop criteria, has been described in multiple reports with atezolizumab, nivolumab, and pembrolizumab (76,77). Shah et al (87) examined several published cases of ICI-related tumor lysis syndrome. They note that the risk factors that need to be taken into consideration for tumor lysis syndrome include chemosensitivity of the tumor, the burden of the disease includes size >10 cm, bone marrow involvement, and pretreatment hyperuricemia and hyperphosphatemia (76,77).…”

“…They note that the risk factors that need to be taken into consideration for tumor lysis syndrome include chemosensitivity of the tumor, the burden of the disease includes size >10 cm, bone marrow involvement, and pretreatment hyperuricemia and hyperphosphatemia (76,77). Although infrequently reported, hypoparathyroidism can occur as an immune-related adverse event of checkpoint inhibitors (76,77,87).…”