A 72‐year‐old‐man with hypertension and right hip pain presented with sudden presyncopal symptoms while seated. He was tachycardic and hypotensive and was noted to have creatinine 4.7 mg/dL (baseline 0.9 mg/dL), potassium 4.6 mEq/L, calcium 6.3 mg/dL, phosphate 6.6 mg/dL, and alkaline phosphatase 1,138 U/L with normal gamma‐glutamyl transpeptidase. Exam was notable for ecchymosis on his chest, flank, and arm that had appeared one hour previously despite no history of trauma. Subsequent inpatient evaluation revealed uric acid 14.7 mg/dL, confirming tumor lysis syndrome (TLS) with unknown malignancy for which the patient received rasburicase. Repeat labs five hours later showed a drop in hematocrit from 31% to 22% and the patient was found to be in disseminated intravascular coagulation (DIC) with PTT 37 seconds, INR 1.9, and fibrinogen 90 mg/dL. Abdominal CT revealed large retroperitoneal hemorrhage with intramuscular hematoma. The patient was managed supportively. 15 hours after rasburicase administration, electrolytes normalized and creatinine decreased to 2.6 mg/dL with return to baseline by hospital day 5. Prostate specific antigen subsequently returned greater than detection limit, bone scan showed widely metastatic disease including a large focus in his right femur. Biopsy of a left iliac lymph node revealed metastatic carcinoma with prostatic primary.
TLS and DIC are both life‐threatening complications of malignancy and thus early recognition is critical to patient survival. TLS is most commonly seen in hematologic malignancies after chemotherapy administration and is the result of widespread tumor cell lysis leading to the characteristic hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and renal failure. TLS from solid tumors is extremely rare and has been described in prostate cancer in only five previous case reports. In all cases, patients were on therapy for prostate cancer and had extensive skeletal metastases. This is the first reported case of spontaneous TLS in untreated prostate cancer and represents a previously unrecognized complication of prostate cancer. Lin et al described a case of spontaneous TLS in a patient with progressive disease despite androgen therapy. DIC is a more readily recognized complication of solid tumors and is a result of tumor cells expressing procoagulants and fibrinolytic inhibitors. However, prostate cancer carries a rare and unique risk of acute hemorrhage compared to the more common presentation of chronic DIC in solid tumors. Prostate tumor overproduction of plasminogen activators and/or depletion of fibrinolytic inhibitors are postulated mechanisms for this excess hemorrhagic risk. In the largest published case series of DIC in prostate cancer by Hyman et al, no patients had thromboses and 39 of 42 cases (93%) had skeletal metastases. Skeletal metastases appear to be a shared risk factor in TLS and DIC in patients with prostate cancer. This case represents the only reported adult patient with concurrent acute development of DIC and TLS in a solid tumor.
Spontaneous TLS is a previously unrecognized complication of untreated prostate cancer. Clinicians evaluating renal failure and electrolyte derangement in patients with metastatic prostate cancer should consider TLS on the differential, especially in cases of extensive skeletal involvement. These patients are also at increased risk of acute hemorrhagic DIC, an under‐recognized complication of prostate cancer.
To cite this abstract:Nguyen R, Ticona L. Spontaneous Tumor Lysis Syndrome – a Previously Unrecognized Complication of Untreated Prostate Cancer – and Dic As the Initial Presentation of Metastatic Prostate Cancer. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 542. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/spontaneous-tumor-lysis-syndrome-a-previously-unrecognized-complication-of-untreated-prostate-cancer-and-dic-as-the-initial-presentation-of-metastatic-prostate-cancer/. Accessed April 26, 2019.