Intraoperative tumor lysis syndrome in a giant teratoma: a case report
Tumor lysis syndrome is an unusual metabolic emergency in solid tumors. Perioperative occurrence of this syndrome is extremely rare but may have fatal consequences if not detected and treated on time.
We report a 19-year patient with testicular germ cell tumor after first line chemotherapy with giant growing teratoma syndrome in retroperitoneum. He underwent radical resection, however, perioperatively, a fatal case of heart failure due to unrecognized intraoperative tumor lysis syndrome developed.
Surgeons, anesthesiologists and oncologists should be aware of this complication in order to be prepared for such an emergency.
KeywordsSurgery Teratoma Genitourinary neoplasm Necrosis Intraoperative
Cyclofosfamide, bleomycin, etoposide, cisplatin, TIP paclitaxel, ifosfamide and cisplatin
Inferior caval vein
Superior mesenteric artery
Tumor lysis syndrome
Tumor lysis syndrome (TLS) is an oncometabolic emergency resulting from rapid cell death. It is reported that TLS can usually occur as a consequence of tumor-targeted therapy (chemotherapy, embolization therapy and radiation therapy) or spontaneously [1, 2]. Perioperative occurrence of this syndrome is extremely rare but may have fatal consequences if not detected and treated on time [3, 4].
We present a case of a young man who developed a hyperkalemic cardiac failure due to TLS during surgery for a giant retroperitoneal teratoma. The aim of this report is to have the knowledge about the possibility and occurrence of this unusual complication and to be aware of such an emergency.
Patient was admitted 1 week before scheduled surgery for nutritional support, preoperative anesthesiologic evaluation, and isotope renography to evaluate actual renal functions.
Preoperative surgery planning
Complete tumor resection in the abdomen as well as in the mediastinum was planned, leaving the supraclavicular tumor for subsequent surgery if needed. As isotope renography revealed a functionless right kidney, autotransplantation of the left kidney was planned at the end of the procedure. Patient and family were informed about the probability of losing both kidneys. Together with vascular surgeons we considered performing a two-stage procedure – an extra anatomic bypass (axillo –bifemoral) first, followed by subsequent tumor resection to achieve ischemia-reperfusion time shorter. Based on our previous experiences we decided to perform a one stage procedure while selectively considering the need of the extra anatomic bypass intraoperatively – in regards to the estimated length of the aortal and caval clamping. We planned to perform Y bypass reconstruction of the aorta as well as the inferior caval vein with optional left kidney autotransplantation according to intraoperative finding on the left renal vessels.
Discussion and conclusions
TLS is basically characterized by hyperkalemia, hyperphosphatemia and hyperuricemia, which has been described by Cairo and Bishop in their definition for both laboratory and clinical criteria [6, 7]. TLS is a relatively rare event in patients with solid tumors and reports about its presentation in testicular cancer are even less common, counting no more than 10 cases in the review articles published up to now [1, 8, 9]. Most often TLS occurred in patients with solid cancers as a result of some form of cancer-targeted therapy (radiation, chemotherapy or hormonal therapy) and even after biopsies . Reports about its intraoperative presentation are even less common, including only a few case reports and no TLS in patients with growing teratoma syndrome was reported [3, 8].
We arrived at the provisional diagnosis of TLS after taking into account a very unusual cause of death with no other explanation. Patient was stabilized for almost the whole course of the surgery with very fast deterioration during the final part of the surgery, with no signs of hypovolemia and before planned reperfusion was done. We assumed that partial tumor devascularisation during its mobilization and tumor manipulations and serial compressions during resection led to multifocal partial tumor necrosis with subsequent release of potassium and other products from the ischemic tumor with subsequent severe metabolic disturbances finally leading to patient’s death.
Clinicians should keep in mind that patients with solid tumors may develop this potentially deadly syndrome. Based on the current literature it seems that patients with advanced and metastatic tumors may be at risk for TLS. Other potential risk factors might be the presence of elevated baseline creatinine and decreased renal function, elevated lactate dehydrogenase, elevated phosphorus, elevated potassium and elevated uric acid [8, 10]. It is also essential to keep in mind that TLS can occur intraoperatively in giant solid cancers. Our patient had an advanced, metastatic tumor, as well as decreased renal function, and therefore was at high risk for developing TLS.
From a surgical point of view, after experiencing this complication, we suggest and will perform stricter perioperative potassium level monitoring in the future, as hyperkalemia is the most life-threating manifestation of TLS and was also the main manifestation in the presented case. We also suggest clamping outflow from the tumor as soon as possible during the surgery, even if it will require the use of extracorporeal circulation support or two stage procedure with extracorporeal bypasses done during the first stage. We will also consider intraoperative use of renal replacement therapy in those patients with planned giant abdominal tumor resections with preoperative renal dysfunction. These kinds of procedures should be performed in centers where such intraoperative interventions are available.
For the first time we report a case of tumor lysis syndrome in giant retroperitoneal teratoma, triggered by surgery. The aim of our paper is to draw attention to this unusual intraoperative complication and make surgeons, anesthesiologists and oncologists aware of this complication and its occurrence even in solid well-differentiated tumors.
We would like to acknowledge the patient’s mother for consent to publish this case report as well as Georgina Kolnikova M.D., PhD., Department of pathology, National Cancer Institute, Slovakia and Pavel Janega M.D., PhD., Department of Pathology, Comenius University, Slovakia for providing photo documentation and descriptions of microscopic findings.
Authors contributed to the conception and design (DP, KR, MM), to the writing of the manuscript (DP, KR, MT), and the acquisition of data and interpretation of data (JP, DP, MM). All authors read and approved the final manuscript.
This work was supported by the Slovak Research and Development Agency under contract No. APVV-15-0086. Funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
Ethics approval and consent to participate
The study was approved by the institutional review board and ethics committee of the National Cancer Institute.
Bratislava, Slovakia and a waiver of consent was granted.
Consent for publication
A written consent from patient’s mother was obtained. A copy of written consent is available for the journal.
The authors declare that they have no competing interests.
- 4.La Spina M, Puglisi F, Sullo F, Venti V, Cimino C, Bellia F, Lo Nigro L, Marino S, Di Cataldo A, Russo G. Tumor lysis syndrome: an emergency in pediatric oncology. J Pediat Biochem. 2015;5(4):161–8.Google Scholar
- 7.Cairo MS, Coiffier B, Reiter A, Younes A. Recommendations for the evaluationof risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: An expert TLS panel consensus. Br J Haematol. 2010;149(4):578–86. https://doi.org/10.1111/j.1365-2141.2010.08143.x.CrossRefPubMedGoogle Scholar
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