In this case report we described a rare

In this case report, we described a rare case of tumor lysis syndrome associated with the FOLFOX regimen and further stress the importance of additional prophylaxis for the huge tumor burden. Our patient\'s hyperammonemia may be due to cardiogenic shock, post cardio-pulmonary-cerebral resuscitation, shock liver or tumor lysis. The causes of hyperammonemia include increased ammonia production (such as infection, GI bleeding, trauma, cancer, or chemotherapy), decreased ammonia 3,3\',5\'-Triiodo-L-thyronine what (such as acute liver failure, cirrhosis), and drug-induced hyerammonemia. Also, a previous case report had mentioned rectovesical and ileal fistulae-related hyperammonemia encephalopathy. We had repeat ammonia data after this acute episode, which showed the ammonia numbers to be around 90ug/dL. We suggested that the patient with chronic hyperammonemia and worsened by the shock episode and 5-FU was continuous-infusion related. To the best of our knowledge, this is the second case report in the literature about tumor lysis syndrome occurring in a colon cancer patient treated with FOLFOX regimen. However, our case is unique and quite different from the quoted paper. First, our patient suffered from hyperammonia that could be aggravated by 5-FU, which was simultaneously complicated with tumor lysis syndrome and resulted in a change of consciousness and critical condition. In the very beginning, we did not think of the possibility of tumor lysis since it is rare. Not until the patient had ventricular fibrillations twice with hyperkalemia did we think of the possibility of tumor lysis. The delayed use of CVVH can still save a patient\'s life. However, our patient received only one day of chemotherapy. Once it is identified, renal replacement therapy is essential for emergency tumor lysis treatment. In this case, we prescribed renal replacement therapy at day 7 after chemotherapy with preserved renal function and corrected metabolic encephalopathy. A earlier study suggested that continuous veno-venous hemodiafiltration is more effective in reducing the phosphate level than conventional hemodialysis. The drastic response even after a delay in performing dialysis in our case suggests that there may be chemotherapy related toxicity post chemotherapy, and continuous dialysis for up to 2 weeks may be needed. Cardiac echography was arranged on day 3 and showed regional wall abnormality with reduced LV systolic function (LVEF: 23%). Regarding differential tumor lysis syndrome and 5-FU related cardiotoxicity, we had reviewed this patient\'s risk in conjunction with the chemotherapy regimen. The 5-FU related cardiotoxicity is a rare complication with the incidence around 1.6–3% in the short regimen, and 7.6–18% in the longer regimen. We suspected that 5-FU related cardiotoxicity was less likely because the 5-FU dose in our regimen was only a median dose, and the patient had not even completed the 1st day of the 5-FU regimen. The cardiac toxicity on the patient may be due to both chronic kidney disease and suspected congestive heart failure and aggravated on moderate dose 5-fu (but lacking data for baseline heart function). Oxaliplatin sensitivity is related to cytokines and histamine, and often presents with predominantly mild symptoms of flushing, heart rate and blood pressure alternation, dyspnea and chest discomfort. Symptoms usually subsided after discontinuation of drug and administration of steroid and antihistamine. For the above reason, we suggested oxaloplatin is less likely in our patient.
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Introduction Hepatocellular carcinoma (HCC) is the third most common cancer and is a leading cause of cancer death in Taiwan. The prognosis is fatal without any treatment, and the 1- 2- and 3-year survival rate is 54%, 40%, and 28%, respectively. Even with treatment, the mortality of this disease is still very high, and the median survival is 17.7 months, while the 5-year survival rate is 10.7%. Spontaneous remission of malignant tumors is a rare phenomenon, and the first case defined in 1959 by Cole and Everson. Spontaneous remission of HCC is an extremely rare phenomenon and the underlying mechanisms of HCC with spontaneous regression still remain unclear. Two mechanisms have been suggested to explain the etiology of HCC with spontaneous regression, either through tumor ischemia, or systemic inflammation. However, those mechanisms cannot appropriately explain all reported cases of HCC with spontaneous regression. We report a case of HCC without any treatment, and spontaneous partial regression was noted.