Tumor lysis syndrome (TLS) is a life-threatening oncological emergency, characterized by hyperuricemia, electrolyte abnormality, and acute kidney injury (AKI). TLS usually occurs during chemotherapy, but rarely occurs before chemotherapy as spontaneous TLS (STLS). We describe a 54-year-old man who showed general fatigue. Laboratory tests showed myeloblasts in peripheral blood, marked elevations of serum uric acid (67.9mg/dL), hyperphosphatemia, and severe renal dysfunction. Bone marrow biopsy findings were compatible with high-grade B-cell lymphoma (HGBCL). The patient was diagnosed with AKI in STLS caused by HGBCL, and hemodialysis was initiated on hospital day 2. However, hyperuricemia and anuria persisted. Chemotherapy was required. Therefore, continuous hemodiafiltration (CHDF) was performed instead of intermittent dialysis from hospital day 9 alongside chemotherapy. Rasburicase was given once on hospital day 12. After five days, serum uric acid and creatinine levels improved, and urine output increased, allowing discontinuation of CHDF. No adverse effects of chemotherapy, aggravated renal dysfunction, or TLS relapse were detected. Unfortunately, the patient died of alveolar hemorrhage on hospital day 61, despite normal renal function. In this case, AKI in STLS hindered prompt decision-making for chemotherapy because of concerns about further renal disorders after initiating chemotherapy. Switching to CHDF to sustainably correct hyperuricemia and electrolyte abnormalities resulted in favorable renal outcomes without complications. Although evidence regarding the efficacy of CHDF against TLS-induced AKI remains very limited, we suggest that management with CHDF for AKI in STLS or TLS is reasonable to prevent TLS aggravation during chemotherapy and to avert renal toxicity from the chemotherapy itself.

Abstract We present the case of a 54-year-old male with nasopharyngeal cancer accompanied by huge liver metastasis, an extremely high Epstein–Barr virus viral load, and B symptoms. Despite aggressive hydration and close laboratory monitoring, he developed tumor lysis syndrome (TLS) and acute kidney injury after the first cycle of chemoimmunotherapy. Although the tumor exhibited an excellent response, the patient became dialysis dependent for 8 months. This case highlights the risk of TLS in patients with nasopharyngeal carcinoma with high tumor burden, a rare but easily overlooked complication.

Introduction: Acute lymphoblastic leukemia (ALL) is typically a childhood disease but may present in older patients in rare occurrences. Due to its significant morbidity and mortality, early diagnosis is crucial. The symptoms of ALL may be non-specific, making the initial diagnosis difficult leading to delayed treatment. Case Report: We present the case of a 34-year-old, healthy male runner presenting to the emergency department with a common complaint of bilateral knee pain, who was ultimately diagnosed with ALL with signs of tumor lysis syndrome leading to premature death. Conclusion: We discuss the presenting symptoms of acute lymphoblastic leukemia, which may include joint or knee pain as well as leukemic arthritis. We further discuss the importance of clinicians maintaining a high level of suspicion for the “bounce-back” patient and avoiding taking cognitive shortcuts.

The safety data on zolbetuximab, a new CLDN18.2-targeting antibody for advanced gastric cancer (AGC), are still exiguous. We report herein a 75-year-old, male patient with CLDN18.2-positive, HER2-negative AGC with weight loss, massive nodal disease, and peritoneal carcinomatosis-related obstructive uropathy. First-line zolbetuximab plus mFOLFOX6 triggered grade 2 nausea, which was followed on day 3 by tumor lysis syndrome (TLS) and 5-fluorouracil (5-FU)-induced hyperammonemic encephalopathy. Discontinuation of 5-FU and supportive care consisting of hydration and rasburicase led to rapid clinical improvement. Chemotherapy, which was resumed after a dosage adjustment, achieved tumor shrinkage and resolved the hydronephrosis. To the best of our knowledge, the present study is the first to describe concurrent TLS and 5-FU-induced encephalopathy during the administration of a zolbetuximab-based regimen and highlights the need for proactive prophylaxis against TLS and for controlling nausea in AGC patients with a high tumor burden, baseline renal impairment, and cachexia.

Epcoritamab monotherapy for Richter transformation (EPCORE CLL-1): findings from a single-arm, multicentre, open-label, phase 1b/2 trial.

Background and Objectives: Hyperleukocytosis in acute myeloid leukemia (AML) is life-threatening, often complicated by leukostasis, tumor lysis syndrome (TLS), and disseminated intravascular coagulation (DIC), with very high early mortality. Leukapheresis (LA) can rapidly reduce circulating blast burden, but its effect on survival and prognostic relevance of disease markers remains unclear. Materials and Methods: We retrospectively analyzed 74 adult AML patients with WBC > 100 × 109/L treated at the University Clinical Center of Serbia between 2014 and 2024: 28 received LA plus cytoreduction (LA group), and 46 received cytoreduction alone (non-LA group). We evaluated 15-, 30-, and 90-day mortality and overall survival (OS), and assessed clinical, laboratory, and immunophenotypic predictors using Cox regression, with separate subgroup analyses. Results: Patients in the LA group had significantly higher baseline leukocyte counts and LDH (p = 0.18 and p = 0.024, respectively). Although LA resulted in a median 34% reduction in WBC, there was no statistically significant difference in early mortality: 15-day survival was 68% vs. 76% (HR 0.70, p = 0.423), 30-day survival 50% vs. 65% (HR 0.62, p = 0.197), and 90-day survival 39.3% vs. 41.3% (HR 0.85, p = 0.604). Median OS was similarly poor, about 1 month in the LA group compared to 2 months in the non-LA (HR 0.73). Across all patients, ECOG PS ≥2, elevated LDH, TLS, and DIC were the strongest indicators of early death. In the LA group, elevated LDH and increased peripheral blood (PB) monocyte count predicted 15-day mortality (p = 0.021 and p = 0.031, respectively), but lost significance by day 90. In non-LA patients, CD25 positivity (p = 0.034) and DIC (p = 0.045) predicted 15-day death. By day 90, CD25 expression (p = 0.048) remained prognostic, while PB blast percentage (p = 0.045) and PB monocyte count (p = 0.017) emerged as additional adverse prognostic predictors in the non-LA group. In multivariate analysis, higher PB blast percentage, CD25 positivity, and ECOG PS ≥ 2 independently predicted poorer OS. Conclusions: Although LA did not reduce early mortality in the entire cohort, the loss of prognostic significance of elevated LDH, high PB blast percentage, PB monocyte burden, and CD25 expression in the LA group may suggest that the intervention can attenuate the impact of biologically aggressive disease.

Background/Objectives: Rasburicase is licensed for the management of tumor lysis syndrome (TLS) at a daily dose of 0.2 mg/kg intravenously for five days. The use of a single-dose treatment is popular in adult oncology but information in pediatric use is limited. Methods: From a literature search, all case reports and series, and comparative studies in which pediatric oncology patients received a single dose of rasburicase were selected for further analysis. Treatment success was determined by normalization of serum uric acid in the absence of serious complications. Results: Twelve articles with a total of 243 children were included. A fixed-dose regimen was used in 195, while 153 received weight-based dosing. With fixed dosing, successful treatment was seen in 91.8% and 82.9% at rasburicase doses ≥3 mg and 1.5 mg, respectively (p = 0.23). However, there were four mortalities in the lower-dose group. For weight-based dosing, success was observed in 89.2% and 66.7% at doses ≥0.15 mg/kg and <0.15 mg/kg, respectively (p = 0.0029). One child required dialysis in the lower-dose group. Conclusions: Single dose of rasburicase for the prophylaxis and treatment of TLS in pediatric oncology is an appealing approach with potentially less financial impact and drug toxicity. A fixed dose of at least 3 mg or 0.15 mg/kg by body weight is recommended.

PurposeComplications such as tumor lysis syndrome occur during the Chimeric antigen receptor (CAR)-T cell treatment process, which adversely affects the treatment effect. The aim of this study is to study the combination of personalised rational medication monitoring and the Knowledge, Attitude, and Behavior (KABP) model health education to improve the adherence and prognosis of CAR-T cell therapy.Patients and Methods91 patients with lymphoma and multiple myeloma who received CAR-T cell therapy in our hospital from January 2021 to December 2024 were included in this single-retrospective study and divided into the control group (n=46, routine care) and the observation group (n=45, routine care + personalised rational medication monitoring combined with KABP model health education) based on the treatment methods. Compliance, clinical treatment efficacy, self-care ability, Functional Assessment of Cancer Therapy-General (FACT-G) scale, State-Trait Anxiety Inventory (STAI), and Knowledge, Attitude, and Behavior (KAB) scale were compared between the two groups.ResultsThe observation group demonstrated significantly higher total compliance and clinical efficacy compared to the control group (P < 0.05). Following personalized rational drug monitoring and KABP model health education post-management, the observation group also exhibited higher scores in self-care ability, FACT-G, and KAB, along with lower STAI scores than the control group (P < 0.05).ConclusionThis approach proves beneficial in enhancing patient adherence, treatment effectiveness, and quality of life in CAR-T cell therapy.

Rasburicase is used to prevent and treat tumor lysis syndrome (TLS) by breaking down uric acid. Administration methods vary, including fixed, weight-based (0.15-0.2 mg/kg), single and multiple doses. Our primary objective is to describe rasburicase use in both adults and children for TLS prevention and treatment. Secondary objectives are to describe the efficacy and safety of different regimens inventoried. Exploratory objective is to estimate savings associated with use of a single fixed dose. Retrospective descriptive study conducted among patients who received rasburicase for TLS prevention or treatment between January 2014 and April 2024 in 3 oncology services of the Hospital Center. A total of 133 adults and 60 children were included, of which 42.9% and 5.0%, respectively, presented biochemical TLS pre-rasburicase. A single 6 mg dose was administered in 86.5% of adults and 21.7% of children. Multiple daily doses were used in 24.8% of adults and 76.7% of children. Few adults (1.5%) received weight-based doses, contrary to children (76.7%). Normalized uric acid (< 476 μmol/L) was observed in 97.9% of patients 24 hours after a first dose, with no serious adverse events. Estimated savings were 86 542.92 CA$ if all patients included (n = 193) received a single 0.15 mg/kg dose, capped at 6 mg. In the adult and pediatric population, a single rasburicase dose of 0.15 to 0.2 mg/kg, capped at 6 mg, represents an effective, safe, and more cost-effective option for both the prevention and treatment of TLS. Further studies are warranted to compare single versus multiple dosing in pediatric population and to identify potential risk factors for nonresponders.

Hematopoietic stem cell transplantation (HSCT) and chimeric antigen receptor (CAR) T-cell therapy have transformed the treatment of hematologic malignancies, with expanding applications in selected solid tumors and nonmalignant hematologic conditions, but are frequently complicated by kidney dysfunction. Acute and chronic kidney disease after HSCT are often multifactorial, with several unique causes such as capillary leak syndrome, sinusoidal obstruction syndrome, transplant-associated thrombotic microangiopathy, and post-transplant nephrotic syndrome playing important roles. Key drivers of CAR T-cell therapy-related kidney disease include sepsis, cytokine release syndrome, and tumor lysis syndrome. Understanding of these injury mechanisms is critical to optimizing prevention, early detection, and management of kidney complications in these populations, with the overall goals of improving kidney and overall outcomes.

Isatuximab, approved for the treatment of relapsed/refractory multiple myeloma in 2020, lacks sufficient long-term safety profile in real-world clinical practice. Leveraging the FDA adverse event reporting system over a 5-year period, this study conducted a comprehensive pharmacovigilance study integrating 4 disproportionality analyses to identify isatuximab-related adverse events. Data extraction and standardization from FAERS were conducted using R and MedDRA. Concurrently, transcriptomic profiling via single-sample Gene Set Enrichment Analysis (ssGSEA) of 50 hallmark gene sets elucidated potential immunological mechanisms. Among 1884 AE reports attributing isatuximab as the primary suspect, significant signals emerged across 25 system organ classes and 129 preferred terms, with high disproportionality for neutropenia, pneumonia, and kidney injury. Tumor lysis syndrome and hypoproteinemia were newly detected and unlisted on the drug label, while females demonstrated elevated urinary tract infection risk. Transcriptomically, the CD38-high group exhibited marked upregulation of immune activation such as interferon gamma response and metabolic stress pathways including fatty acid metabolism and apoptosis, suggesting a dual phenotype of immunosuppression and hyperinflammation that may predispose to infections and renal toxicity. By synergizing real-world pharmacovigilance with transcriptomic data, this study delineates novel clinical AE signals and mechanistic insights linking CD38-driven immunometabolic dysregulation to isatuximab toxicity. These findings underscore the imperative for vigilant monitoring and tailored therapeutic strategies to mitigate risks of immune dysfunction, informing both clinical practice and future biomarker-driven interventions.

High risk and low incidence diseases: Tumor lysis syndrome.

Safety, tolerability, and pharmacokinetics of lisaftoclax (APG-2575)-based therapy in patients with chronic lymphocytic leukemia: Phase 1b/2 study.

IntroductionThe safety concerns of Bruton's tyrosine kinase inhibitors (BTKis) have garnered significant attention due to their severe adverse reactions. However, no existing studies have utilized VigiBase, the world's largest adverse event reporting system, to conduct post-marketing safety analyses of these agents. MethodsThis study extracted data from VigiBase and the FDA Adverse Event Reporting System (FAERS), employing the reporting odds ratio as the primary method and information component as supplementary, to comprehensively evaluate the safety profiles of ibrutinib, acalabrutinib, and zanubrutinib, with a focus on bleeding risks when combined with anticoagulants or antiplatelet drugs. ResultsThe results revealed that at the system organ class level, ibrutinib had the strongest signal in cardiac disorders; acalabrutinib in blood and lymphatic system disorders; and zanubrutinib in infections and infestations and blood and lymphatic system disorders. Among the top ten standardised medical dictionary for regulatory activities queries (SMQ), the SMQs with the strongest signals were different for each BTKis, but five identical SMQs were in the top ten, namely supraventricular tachyarrhythmias, tumour lysis syndrome, haematopoietic thrombocytopenia, haemorrhage terms (excl laboratory terms), and haemorrhage laboratory terms. At the preferred term level, acalabrutinib exhibited the strongest signal for Richter’s syndrome, zanubrutinib for subcutaneous haemorrhage, while ibrutinib displayed divergent signals between databases—Bing-Neel syndrome in VigiBase and haematotympanum in FAERS. Importantly, bleeding risks varied significantly between monotherapy and combination therapy with anticoagulants/antiplatelet agents, underscoring the need for clinical vigilance regarding site-specific haemorrhage risks.DiscussionThese results will provide new data to support the use of BTKis and further safety warnings. However, as a hypothesis-generating approach, it does not establish a definitive causal relationship, which will require further research and validation.

ABSTRACTIntroductionTumor lysis syndrome (TLS) arises from the rapid breakdown of tumor cells during oncological treatment. Although TLS is rarely observed in solid tumors, few studies have documented instances of TLS associated with pembrolizumab. This report presents a case involving pembrolizumab‐induced TLS.Case PresentationA 76‐year‐old male patient with advanced renal pelvis cancer (T3N2M1) was treated with pembrolizumab as second‐line therapy. Four days after the initiation of therapy, the patient developed TLS. Despite intensive therapeutic interventions, he succumbed to the condition on the 10th day.ConclusionThis case highlights a fatal TLS episode after pembrolizumab. Given its poor prognosis, blood monitoring and prophylaxis are warranted in intermediate‐risk patients, particularly when multiple non‐renal risk factors are present.

Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency marked by severe metabolic abnormalities, including hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Although commonly associated with hema.

This multicenter, retrospective study evaluated the efficacy and safety of the venetoclax plus decitabine, cytarabine, aclarubicin, and granulocyte colony-stimulating factor (VD-CAG) regimen in newly diagnosed acute myeloid leukemia (ND-AML) patients aged 18-60. The analysis included, but was not limited to, the composite complete response (CRc) rate, measurable residual disease (MRD) negativity rate, overall survival (OS), event-free survival (EFS), and safety. A total of 107 adult patients with AML were included in the study, conducted between March 1, 2022, and December 31, 2024. The median age was 49 years (range: 18-60 years), with a male-to-female ratio of 44:63. The CRc rate after one cycle of the VD-CAG regimen was 86.9% (95% CI 79-92.7; 93 of 107 patients) in the entire cohort. 73 (79%) of 93 patients who reached CRc had undetectable MRD. Grade 3 or worse adverse events included neutropenia in 107 (100%) of 107 patients, thrombocytopenia in 107 (100%), anemia in 107 (100%), febrile neutropenia in 57 (53%), pneumonia in 10 (9.3%), sepsis in five (4.7%), and tumor lysis syndrome in three (2.8%). No treatment-related deaths occurred. With a median follow-up of 8.8 months (range: 1-33.5 months), the median EFS and OS are not reached. The estimated 12-month OS was 90% (95% CI 90-95) and 12-month EFS was 79% (95% CI 69-87). The VD-CAG regimen represents an effective induction therapy for young ND-AML. It leads to high rates of CRc and MRD-negative remissions, along with encouraging OS and EFS across prognostic subgroups.

Background: Numerous international studies of Acute Lymphoblastic Leukemia (ALL) published in recent years have conclusively demonstrated that minimal residual disease (MRD) during the induction phase is the most reliable prognostic indicator in newly diagnosed ALL. Methodology: This study included 53 newly diagnosed children with ALL who received chemotherapy at Almojtaba (BMTC) from August 1, 2023, to December 30, 2024. During the induction phase, patients were treated according to the Total XV protocol. Statistical analysis was performed using SPSS version 2022. Results: Of the 53 participants, 29 were female (54.7%) and 24 were male (45.3%). T-cell ALL was diagnosed in 14 patients (26%), with 4 of them (7.5%) remaining MRD-positive at day 42. In comparison, only 3 patients (5.6%) with B-cell ALL were MRD-positive at day 42. The most common complication observed during induction was adjustment disorder, affecting 9 participants (15.7%), followed by local skin infection (cellulitis) in 5 patients (9.4%), and pneumonia in 4 (7%). Acute renal failure with tumor lysis syndrome, sepsis, and cardiac dysfunction were each observed in 1 patient (1.7%). There was no significant association between MRD status at day 42 and the presence of underlying comorbidities. Additionally, no statistically significant association was found between sex and MRD outcomes at day 15 and day 42 (p-values 0.5 and 0.09, respectively), as determined by Fisher’s exact test. The induction mortality rate was 1.7%. Conclusion: Most complications encountered during the induction phase of pediatric ALL treatment are manageable and typically arise due to the aggressive nature of the disease, the intensity of chemotherapy, or the presence of pre-existing comorbidities. While these complications may cause temporary treatment interruptions, they generally do not affect overall induction outcomes. The majority of patients achieve remission by the end of induction.

Immunotherapy has transformed oncology, yet kidney complications increasingly affect outcomes. This review summarizes nephrotoxicity from immune checkpoint inhibitors (ICIs), chimeric antigen receptor T-cell (CAR-T) therapies, and bispecific T-cell engagers (BiTEs). ICIs remain most used, with acute interstitial nephritis (AIN) as the hallmark lesion, while glomerular diseases and electrolyte abnormalities are less common. CAR-T therapy, though highly effective in hematologic cancers, carries risks of cytokine release syndrome, tumor lysis syndrome, and acute kidney injury (AKI). BiTEs, particularly teclistamab, show higher AKI rates than CAR-T, though mechanisms remain unclear. Early recognition, tailored management, and multidisciplinary collaboration are essential to ensure safe therapy and preserve kidney function.

Evaluation of ventoclax initiation prophylaxis and monitoring outcomes at each dose level and time point in patients with chronic lymphocytic leukemia: A real-world experience