SESSION TYPE: Cancer Cases I
PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM
INTRODUCTION: Prostate is a rare site for Extra Pulmonary Small Cell Carcinoma (EPSCC). We report the first case of Tumor Lysis Syndrome (TLS) that developed in Prostatic EPSCC. This case was complicated by methemoglobinemia and severe hemolytic anemia after rasburicase (recombinant urate oxidase) use.
CASE PRESENTATION: A 56-year-old African American with a metastatic small cell cancer of the prostate developed TLS within 2 day of initiation of chemotherapy. 15 days prior to admission, he had a biopsy of a 1.7 cm hypodense nodule in the left lobe of the prostate that demonstrated poorly-differentiated small cell cancer (immunostain negative for PSA and TTF-1, positive for chromogranin, synaptophysin and CD56). His Serum PSA was 6.1. Extensive metastases to pelvic lymph nodes, liver (despite advanced alcoholic liver cirrhosis), lumber spine and lungs were noted, all with significant uptake on PET CT. Despite intravenous hydration and steroids, his serum creatinine, phosphate and uric acid increased from normal to 4.0, 7.4 and 16 respectively. On day 5, he received a dose of rasburicase. After rasburicase, his uric acid and phosphorus started to decline. However he became tachycardiac, tachypneic and hypoxemic (oxygen saturation in mid-80s on room air). He was noted to have methemoglobinemia (5.9%) for which he was given a dose of methylene blue and was transferred to intensive care unit. His hemoglobin dropped from 13 to 6.6 gm/dl with peripheral smear demonstrating numerous bite cells. Bilirubin increased to 21, LDH peaked at 3234 (baseline 160), haptoglobin <30, absolute reticulocyte count and reticulocyte index peaked at 206 and 82.4, respectively. He received 11 units via red cell exchange transfusion. Patient condition was stabilized and he was transferred to floor with Hemoglobin of 13 g/dl, total bilirubin of 4.4, methemoglobin of 0.6 and creatinine of 4.0.
DISCUSSION: TLS has not been reported in EPSCC of Prostate. This case highlights several important issues in prevention and treatment of TLS. Although our patient had normal baseline Creatinine, LDH and Uric Acid levels, he was at intermediate to high risk for developing TLS due to bulky tumor mass, extensive metastasis, urinary outflow-tract obstruction, high proliferative rate of malignant cells, chemo-sensitive malignancy and acidic urine. At risk patients should receive allopurinol or rasburicase prior to chemotherapy. Rasburicase treatment can induce hemolytic anemia in G6PD deficient cases but its routine measurement is not currently recommended. Methylene blue is not helpful in G6PD deficient cases and should not be used.
CONCLUSIONS: : Tumor Lysis Syndrome should be anticipated and treated with cautions in high risk patients.
1) Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med 2011; 364:1844-1854
2) Bauters T, Mondelaers V, Robays H, et al. Methemoglobinemia and hemolytic anemia after rasburicase administration in a child with leukemia. Int J Clin Pharm 2011; 33:58-6
DISCLOSURE: The following authors have nothing to disclose: Sikander Zulqarnain, Terrence Bradley, Spiro Demitis
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