2262 Too Much TAE: A Case of Tumor Lysis Syndrome After Repeat Transarterial Embolization of Hepatocellular Carcinoma

Abstract

INTRODUCTION: Hepatocellular carcinoma (HCC) is the sixth most common cancer in the world & the second highest cause of cancer-related deaths globally. In the US, HCC incidence has almost tripled since the 1980s & has become the fastest rising etiology of cancer-related deaths. Tumor lysis syndrome (TLS) is a condition that results when malignant cells release their intracellular contents, either spontaneously or in response to cytoxic treatment. The cellular contents result in hyperuricemia, hyperkalemia, hyperphosphatemia, & hypocalcemia; these disturbances can lead to arrhythmias, AKI & death. TLS is common in leukemias & lymphomas but is rare in solid tumors. CASE DESCRIPTION/METHODS: A 50-year-old female with biopsy proven HCC without cirrhosis was admitted for planned transarterial chemoembolization (TACE) of her large right lobe & medial left lobe HCC, measuring 13.3 × 17.9 × 21.8 cm (Image 1), as too advanced for surgical resection or transplant & she had large liver-lung shunt preventing radioembolization treatment. Interventional Radiology (IR) placed two vials of LC beads containing doxirubicin 100mg & bland transarterial embolization (TAE) via 2.5 vials of Embospheres into right hepatic artery. Afterwards, she had acute drop in Hgb with CTA revealing multiple areas of active bleeding in the liver & new hematoma centrally in the mass. IR performed complete embolization of the right hepatic artery using coils & gelfoam to achieve hemostasis; patient was transferred to ICU. She received blood products & lab monitoring, the latter demonstrated new hyperkalemia of 5.5 mmol/L, previously normal. Creatinine increased from 0.55mg/dL to 1.23, thought to be multifactorial. Additional workup revealed uric acid of 12.5mg/dL, calcium 6.9mg/dL & phosphorous 7.4mg/dL. TLS was diagnosed & treated with intravenous fluids for dilution, rasburicase for hyperuricemia, furosemide for renal dysfunction & minimal urine output, & insulin for hyperkalemia. DISCUSSION: HCC is a growing health burden, & advanced tumors that are not candidates for surgical resection are commonly treated with radiofrequency ablation, TACE, TAE, & chemotherapy. Early recognition of TLS is key for treatment & involves awareness of the propensity for development of TLS in large tumor burdens, rapidly dividing tumors, multiple treatment sessions, & pretreatment renal dysfunction. Oliguria after IR treatment of HCC should raise the suspicion for possible TLS & not be easily dismissed as the common but less fatal contrast induced nephropathy.