A Late and Delayed Case of Rhabdomyolysis with Trabectedin Use

Introduction: Trabectedin, a marine-derived alkylating agent, is used in treating Liposarcoma by disrupting the cell cycle and inducing cancer cell death. It, however, has been associated with rhabdomyolysis. What sets this case apart is the delayed onset of Trabectedin-induced rhabdomyolysis, manifesting approximately 3 weeks after the patient's last dose. Case Description: 38-year-old female with a history of liposarcoma of the left femur with disease progression despite surgery and chemotherapy, has been undergoing palliative chemotherapy with trabectedin. She presents with fever and generalized weakness and laboratory evaluation showed a Creatinine Kinase (CK) level of 2751 U/L. She developed an acute kidney injury with a creatinine of 5.09 mg/dL. CK levels peaked on day 20 from the last dose at 10915 U/L. Trabectedin induced rhabdomyolysis was diagnosed and patient was started on hemodialysis. On outpatient follow-up, her renal function improved leading to discontinuation of hemodialysis with complete resolution of rhabdomyolysis. Discussion: Trabectedin is an effective drug in treating advanced sarcoma. One of the rare side effects associated with its use is rhabdomyolysis. Its etiology is not completely clear. The most reported cases of rhabdomyolysis associated with Trabectedin occurred on average 2 weeks following the administration of Trabectedin. Most of the cases reported toxicity in the first few cycles of Trabectedin. In our case, rhabdomyolysis occurred 3 weeks after the 5th cycle. Therefore, one should remain vigilant about late and delayed cases of rhabdomyolysis with Trabectedin use. To note, the CK level was elevated after the third cycle at 1,124 U/L. The current recommendation is to check CK after each cycle and to adjust therapy with no discontinuation of therapy unless rhabdomyolysis occurs. This case highlights the need to explore if more stringent CK criteria and monitoring need to be placed to prevent rhabdomyolysis cases.