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Oncology - Tumor Lysis Syndrome - Fast Facts | NEJM Resident 360

Tumor lysis syndrome (TLS) is a medical emergency that occurs when the contents of tumor cells are released into the bloodstream, either spontaneously or in response to therapy.

TLS is primarily associated with aggressive lymphomas and leukemias (e.g., Burkitt lymphoma), acute lymphocytic leukemia, acute myeloid leukemia, and chronic myeloid leukemia blast crisis. Increasingly, TLS is seen with other tumors, including solid tumors.

Risk Factors

• renal dysfunction

• hyperuricemia

• high tumor burden and/or growth rate

• chemosensitivity of the malignancy

• hypovolemia

• hypotension

• acidic urine

The following table provides more information on risk factors:

Diagnosis

The diagnosis of TLS requires two or more of the following clinical abnormalities:

• hyperuricemia (>8 mg/dL)

• hyperkalemia (>6 mmol/L)

• hyperphosphatemia (>4.5 mg/dL)

• hypocalcemia (<7 mg/dL)

A TLS diagnosis also requires one of the following:

• acute renal failure

• cardiac arrhythmia

• seizure

Definitions of Laboratory and Clinical TLS

Pretreatment

Pretreatment for patients identified at high risk for TLS:

• Administer intravenous (IV) normal saline (and diuretics if necessary) to achieve urine output of 2 mL/kg/hr (often sufficient for mild TLS).

• If hyperuricemia is present, an agent to reduce uric acid may be required (either allopurinol or rasburicase). Although rasburicase has been shown to be more effective (and preferred in the presence of renal injury), it is very expensive.

Treatment

• consider intensive care unit (ICU) transfer, depending on clinical status and degree of metabolic derangement (Note: TLS implies a highly responsive tumor and initial response to therapy.)

• lab tests every 4 to 6 hours and treatment of electrolyte abnormalities

• cardiac monitoring

• intravenous fluids (IVF)

• rasburicase for significant hyperuricemia, particularly if renal dysfunction is a concern

• dialysis as a last resort

The following flowchart is helpful for the initial assessment and management of TLS:

Assessment and Management of TLS

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