Fatal Tumor Lysis Syndrome During Radiotherapy for Non–Small-Cell Lung Cancer

Abstract

abbreviations as in Fig 1). A cardiac malignant tumor was suggested. Extensive diagnostic work-up yielded no evidence of extracardiac neoplastic manifestations. Because of the highly compromised conditions of the patient, surgery was considered not feasible. Chemotherapy and supportive treatment were initiated, but patient's conditions rapidly deteriorated with refractory right-sided heart failure. A second CT, performed 9 days after the first one, showed further increase in mass dimensions (9.2 ϫ 7.0 ϫ 8.5 cm; volume 287 cm 3 ; relative increase 24%; mean growth rate 6.1 cm 3 /d). On day 25 after admission in our laboratory, the patient died. Autopsy (Fig 3, panels A-B) confirmed the presence of a large and vascularized right atrial mass (asterisks) characterized by friable and hemorrhagic consistency, thrombotic extension into the SVC (white arrows) and encasement of both electrodes. Histology showed extensive lymphocyte infiltration (Fig 3, panel C), and immunohistochemical analysis revealed staining for CD 20 (Fig 3, panel D), showing the mass to be a large B-cell primary cardiac lymphoma (PCL).PCL represents 1.3% of primary cardiac tumors and 0.5% of extranodal lymphomas. 1 It occurs more commonly in immunocompromised patients, particularly in HIV-positive individuals, whereas its detection in immunocompetent subjects is exceedingly rare. 2,3 Clinical presentations may depend on flow obstruction, infiltration of adjacent tissues, or tumor embolization, and include heart failure, arrhythmias, atrioventricular disturbances, pericardial effusion, SVC syndrome, and stroke. 4,5 Sick sinus syndrome has been reported as a complication of lymphomas with secondary myocardial involvement, 6 but its occurrence as first presentation of PCL is exceptional. The prognosis depends on tumor stage and location, comorbidities, and the immunological status of the patient, but early diagnosis is fundamental to allow prompt initiation of aggressive treatment. 7 Although in most cases this may be achieved by transthoracic echocardiography, the nonspecific clinical presentations often lead to diagnostic delay. In this view, tumor growth rate represents a key aspect in affecting the feasibility of early diagnosis. These images illustrate the massive growth of a PCL characterized by unusual presentation and fatal evolution over less than 24 weeks. Because neither transesophageal echocardiography nor chest CT was performed at the time of pacemaker implantation, the effective stage of tumor mass at that time cannot be established. Nonetheless, the following elements support the hypothesis of an extremely high growth rate: (1) the absence of right atrial masses by transthoracic echocardiography immediately before implantation; (2) the evidence of no

Tumor Lysis Syndrome in Solid Tumors: An up to Date Review of the Literature

“…It is important to note that all of the reported patients had evidence of metastatic disease. Five patients had adenocarcinoma, 10,11,13,14,17 two patients had squamous cell carcinoma, 15,16 and one patient had evidence of mixed NSCLC and SCLC. 12 Five patients developed TLS secondary to chemotherapy.…”

“…13 Two patients developed spontaneous TLS (adenocarcinoma and squamous cell carcinoma respectively), 11,16 and one patient developed TLS secondary to radiation therapy (squamous cell carcinoma). 15 …”

Tumor Lysis Syndrome: New Challenges and Recent Advances

“…4 Among adults, TLS is commonly seen after treatment for ALL, acute myeloid leukemia, and Burkitt’s lymphoma. 5–7 Although TLS is often associated with cytotoxic chemotherapy, reports exist of TLS occurring after treatment with radiation therapy, 8,9 dexamethasone treatment, 10 thalidomide therapy, 11,12 and with newer chemotherapeutic agents including bortezomib and rituximab. 13–15 …”

Radiation-Induced Tumor Lysis Syndrome in Chronic Lymphocytic Leukemia

“…Although it is generally triggered by cytotoxic therapy, it can also be observed spontaneously in cases of bulky tumors. Radiation as a cause of TLS has been rarely reported in the literature [1,2,3]. Here we present a patient with 2 primary malignancies experiencing TLS during palliative radiotherapy.…”