Transcatheter arterial embolization with trisacryl gelatin microspheres (Embosphere®) leads to life-threatening tumor lysis syndrome in a rectal carcinoid patient with hepatic metastases
A 34-year-old man was admitted to our hospital for treatment of multiple hepatic metastases from a rectal carcinoid tumor. He had been treated with local extirpation of a rectal tumor 4 years previously. Abdominal computed tomography (CT) 25 months later revealed multiple liver metastases. The diagnosis was confirmed by liver biopsy, and the tumor cells were immunoreactive to synaptophysin. The patient was then treated with Yttrium-90 selective internal radiation therapy about 1 year and 7 months before this admission. Yttrium-90 resin microspheres (SIR-spheres; Sirtex Medical, Sydney, Australia) mounted with a radioactive load of approximately 50 Bq per sphere were used for radioembolization. One year and 2 months after the Yttrium-90 therapy, a follow-up abdominal CT showed liver metastases in progression. Therefore, further embolization with Embosphere® (BioSphere Medical, Inc., Rockland, MA, USA) was performed.\nThe patient had no past medical history of serious illness such as hypertension, diabetes mellitus, or chronic kidney disease, nor any hospitalization other than treatment for the carcinoid tumor.\nOn physical examination, a huge mass was palpable in the upper abdomen. There was no ascites or signs of encephalopathy. On the day of admission, laboratory results showed hemoglobin 11.3 g/dL, platelet count 207000/mm3, alanine aminotransferase (ALT) 37 IU/L, aspartate aminotransferase (AST) 35 IU/L, albumin 3.9 g/dL, total bilirubin 0.57 mg/dL, lactate dehydrogenase (LDH) 402 IU/L, creatinine 0.8 mg/dL, potassium 4 mmol/L, and prothrombin time 13.5 s. The Child-Pugh class was A.\nOn unenhanced and contrast-enhanced CT, there were more than 20 hepatic tumors in both lobes, with the largest being > 18 cm in diameter (Fig. a and b). Hepatic angiography was performed via a right femoral artery approach (Fig. a and b). A 4-French catheter and a 2.7-French microcatheter were used for celiac trunk and superselective hepatic (segmental and subsegmental) angiography, respectively, revealing multiple tumor stains in both hepatic lobes. TAE was performed by injection of 2 mL 100–300 μm Embosphere® particles in the left hepatic artery's supplying branches and 2 mL 100–300 μm, 2 mL 300–500 μm Embosphere® particles injection in the right hepatic artery's supplying branches until there was sluggish hepatic arterial flow. The coil shown in the picture (Fig. ) was placed during the procedure of Yttrium-90 therapy. Coil embolization of the right gastric artery and gastroduodenal artery could avert reﬂux and thereby decrease the risk of gastric ulcer during Yttrium-90 therapy.\nThree days after TAE, the patient complained of general fatigue and poor appetite. He also became oliguric. Laboratory tests showed ALT 430 IU/L, AST 1910 IU/L, total bilirubin 7.63 mg/dL, LDH 16300 IU/L, creatinine 6.54 mg/dL, potassium 7 mmol/L, phosphorous 10.7 mg/dL, calcium 6.2 mg/dL, and uric acid 13.4 mg/dL. As the patient developed hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, and acute renal failure, the diagnosis of acute tumor lysis syndrome was made. He was first treated with 0.9% saline hydration, then alkalinization of urine with sodium bicarbonate, allopurinol for hyperuricemia, kalimate, and calcium gluconate for hyperkalemia were applied 3 days after TAE. However, anuria developed and he received emergency hemodialysis. Rasburicase was applied for hyperuricemia on the fifth day after TAE.\nAfter intensive care, the patient gained satisfactory recovery of both renal and hepatic functions on day 68 after TAE. Laboratory tests showed ALT 16 IU/L, AST 16 IU/L, total bilirubin 0.58 mg/dL, creatinine 0.79 mg/dL, BUN 12 mg/dL, potassium 3.9 mmol/L, and prothrombin time 12.6 s. Follow-up unenhanced CT scan on day 34 after TAE showed large areas of necrosis (Fig. ).\nBecause of disease progression 1 year later, TAE was performed once more with Embosphere® after prevention for tumor lysis syndrome (adequate hydration and the usage of rasburicase). Neither tumor lysis syndrome nor acute renal failure occurred after this procedure. Finally, the patient died of progressive disease 4 months after the second TAE.