Learning objectives
- Describe tumor lysis syndrome (TLS)
- Management of TLS
Definition and mechanisms
- Tumor lysis syndrome (TLS) is a condition that occurs when a large number of cancer cells die within a short period, releasing their contents into the blood
- Occurs most commonly after the treatment of lymphomas and leukemias and in particular when treating non-Hodgkin lymphoma, acute myeloid leukemia, and acute lymphoblastic leukemia
- TLS can occur spontaneously (before cancer treatment) but is more common within a week of starting treatment
- Not limited to patients receiving traditional chemotherapy, can also occur in patients receiving steroids, hormonal therapy, targeted therapy, or radiation therapy
- Characterized by hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and higher-than-normal levels of blood urea nitrogen (BUN)
- TLS is analogous to rhabdomyolysis
Signs and symptoms
- Nausea with or without vomiting
- Lack of appetite and fatigue
- Dark urine, reduced urine output, or flank pain
- Numbness, seizures, or hallucinations
- Muscle cramps and spasms
- Heart palpitations
- Hyperkalemia and secondary arrhythmias
- Hyperphosphatemia and prologued QT interval
- Hypocalcemia and risk of seizures
- Hyperuricemia and acute renal failure
- Hyperuricosuria
Complications
- Acute uric acid nephropathy
- Acute kidney failure
- Seizures
- Cardiac arrhythmias
Risk factors
| Tumor characteristics | High cell turnover rate Rapid growth rate High tumor bulk |
| Type of cancer | Burkitt’s lymphoma Other Non-Hodgkin lymphomas Acute lymphoblastic leukemia Acute myeloid leukemia |
| Patient characteristics | Baseline serum creatine Kidney failure Dehydration |
| Chemotherapy characteristics | Chemo-sensitive tumors, such as lymphomas Use of steroids |
| Spontaneous tumor lysis syndrome | Triggered without any treatment |
Diagnosis
- Large tumor burden
- Hyperuricemia > 15 mg/dL
- Hyperphosphatemia > 8 mg/d
- Urine analysis: uric acid crystals or amorphous urates
- Detection of hypersecretion of uric acid with a high urine uric acid/creatinine ratio > 1.0
Management
Suggested reading
- Puri I, Sharma D, Gunturu KS, Ahmed AA. Diagnosis and management of tumor lysis syndrome. J Community Hosp Intern Med Perspect. 2020;10(3):269-272.
- Gupta, A., Moore, J.A., 2018. Tumor Lysis Syndrome. JAMA Oncology 4, 895.
- Oduro-Dominah L, Brennan LJ. Anaesthetic management of the child with haematological malignancy. Continuing Education in Anaesthesia Critical Care & Pain. 2013. 13;(5);158-164.
- Behl D, Hendrickson AW, Moynihan TJ. Oncologic emergencies. Crit Care Clin. 2010;26(1):181-205.
- Beed M, Levitt M, Bokhari SW. Intensive care management of patients with haematological malignancy. Continuing Education in Anaesthesia Critical Care & Pain. 2010.10;(6);167–171.
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