CASE REPORT article
Front. Oncol.
Sec. Gastrointestinal Cancers: Hepato Pancreatic Biliary Cancers
Volume 15 - 2025 | doi: 10.3389/fonc.2025.1624908
This article is part of the Research TopicCancer, Metabolism and Kidney Injury: From Molecular Mechanisms to TherapyView all 5 articles
Case Report: Tumor Lysis Syndrome in Advanced, Massive Hepatocellular Carcinoma with Main Portal Vein Invasion Following Atezolizumab plus Bevacizumab Therapy
Provisionally accepted
- 1Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- 2Linkou Chang Gung Memorial Hospital, Linkou, Taiwan
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Tumor lysis syndrome (TLS) is extraordinarily rare in solid tumors. However, the combination of atezolizumab and bevacizumab (AB) in advanced hepatocellular carcinoma (HCC) has raised concerns for abrupt metabolic derangements. We describe a fatal episode of TLS precipitated by AB in HCC with main portal vein (Vp4) invasion, highlighting the need for vigilant risk stratification and early biochemical surveillance for high-tumor-burden disease.A 65-year-old man with chronic hepatitis B and massive HCC (Vp4 invasion) had relatively preserved organ function at baseline. Two days after initiating atezolizumab (1,200 mg) and bevacizumab (15 mg/kg), he developed fever (38.5°C) and tachycardia (heart rate 112 beats/min [bpm]), rapidly progressing to circulatory shock on day 3. Laboratory workup revealed hyperuricemia (12.4 mg/dL), hyperphosphatemia (12.9 mg/dL), hyperkalemia (6.8 mmol/L), hypocalcemia (7.7 mg/dL), and acute kidney injury, meeting the Cairo-Bishop criteria for TLS. Imaging demonstrated abrupt cystic changes of the hepatic mass, suggesting rapid tumor necrosis. Despite aggressive fluid resuscitation and the initiation of hemodialysis, the patient succumbed to multiorgan failure within eight days after initiating AB.This case underscores that advanced HCC with extensive vascular invasion is at risk of severe TLS shortly after potent immuno-antiangiogenic therapy. Clinicians should incorporate thorough baseline risk assessments, prompt laboratory monitoring, and timely intervention into standard care algorithms for high-risk HCC. The rapid metabolic collapse observed here serves as a reminder that while combination therapy holds promise for improving survival in advanced HCC, it can also lead to life-threatening complications in specific subgroups.Careful selection of therapeutic options and shared decision-making with patients are critical to balancing potential benefits against severe adverse events, such as TLS.
Keywords: case report, Tumor Lysis Syndrome, Hepatocellular Carcinoma, atezolizumab plus bevacizumab, systemic therapy, main portal vein invasion
Received: 08 May 2025; Accepted: 23 Jul 2025.
Copyright: © 2025 Chou, Wu, Lin and Hsu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Tienshin Chou, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
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