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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamad Alkateb, MBBCh [2] Synonyms and keywords: TLS; Laboratory Tumor Lysis Syndrome; LTLS; Clinical Tumor Lysis Syndrome; CTLS
Overview
Tumor lysis syndrome (TLS) is a group of metabolic complications that can occur after treatment of cancer, usually lymphomas and leukemias, and sometimes even without treatment. These complications are caused by the break-down products of dying cancer cells and include hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and acute renal failure. If left untreated, patients with tumor lysis syndrome may progress to develop nausea, vomiting, diarrhea, anorexia, hematuria, heart palpitations, and muscle cramps. The diagnosis of tumor lysis syndrome is based on the Cairo–Bishop criteria, which includes hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.[1] Screening for tumor lysis syndrome is not recommended. However, patients with malignancies or acute renal failure should be considered for tumor lysis syndrome workup.[2] Tumor lysis syndrome is a medical emergency and requires prompt treatment.[3]
Classification
Tumor lysis syndrome (TLS) may be classified according to the 1993 Hande-Garrow classification system into two groups: laboratory tumor lysis syndrome (LTLS) and clinical tumor lysis syndrome (CTLS).[1]
Pathophysiology
Tumor lysis syndrome (TLS) is a group of metabolic abnormalities resulting from rapid lysis of malignant cells and massive release of cell breakdown products into the blood among patients with hematologic malignancies treated with chemotherapy. The most common tumors associated with this syndrome are poorly differentiated lymphomas, such as Burkitt's lymphoma, and leukemias, such as acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). Usually, the precipitating medication regimen includes combination chemotherapy, but those patients with lymphoma and ALL can be affected with steroid treatment alone.
Causes
Development of tumor lysis syndrome is the result of initiation of chemotherapy or radiotherapy in cancer patients and sometimes even without treatment.
Tumor Lysis Syndrome Differential Diagnosis
Tumor lysis syndrome must be differentiated from other diseases that cause hyperuricemia, hyperkalemia, and hyperphosphatemia, such as acute kidney injury.[4]
Epidemiology and Demographics
The exact incidence of tumor lysis syndrome has not been established. There is no racial or sex predilection for tumor lysis syndrome.[5]
Risk Factors
The most potent risk factor in the development of tumor lysis syndrome after initiating chemotherapy is kidney disease. Other risk factors include dehydration, hematologic tumors, and solid tumors.
Screening
Screening for tumor lysis syndrome is not recommended. However, patients with malignancies or acute renal failure should be considered for tumor lysis syndrome workup.[2]
Natural History, Complications and Prognosis
If left untreated, patients with tumor lysis syndrome may progress to develop nausea, vomiting, diarrhea, anorexia, hematuria, palpitations, and muscle cramps. Common complications of tumor lysis syndrome include hyperkalemia, hypocalcemia, and hyperphosphatemia. Prognosis is generally good, if not associated with acute renal failure.[6]
Diagnosis
Diagnostic Criteria
The diagnosis of tumor lysis syndrome is based on the Cairo–Bishop criteria, which includes uric acid, potassium, phosphorous, and calcium.[1]
History and Symptoms
Symptoms of tumor lysis syndrome include nausea, vomiting, diarrhea, oliguria, confusion, delirium, and seizure.
Physical Examination
Common physical examination findings of tumor lysis syndrome include edema, cardiac arrhythmia, and tetany.[1]
Laboratory Findings
Laboratory findings consistent with the diagnosis of tumor lysis syndrome include high serum uric acid, potassium, phosphorus, and low calcium.[1]
ECG
Electrocardiogram (ECG) may be helpful in the diagnosis of arrhythmias associated with tumor lysis syndrome.
Chest X Ray
There are no chest x-ray findings associated with tumor lysis syndrome. However, chest x-ray may be useful to detect mediastinal tumors.
Abdominal CT
There are no CT findings associated with tumor lysis syndrome. However, abdominal CT may be useful to detect abdominal tumors or renal masses.
Abdominal MRI
There are no MRI findings associated with tumor lysis syndrome. However, abdominal MRI may be useful to detect abdominal tumors or renal masses.
Abdominal Ultrasound
There are no ultrasound findings associated with tumor lysis syndrome. However, abdominal ultrasound may be useful to detect abdominal tumors or renal masses.
Other Imaging Studies
There are no other imaging studies available for the diagnosis of tumor lysis syndrome.
Other Diagnostic Studies
There are no other diagnostic studies available for the diagnosis of tumor lysis syndrome.
Treatment
Medical Therapy
Tumor lysis syndrome is a medical emergency and requires prompt treatment with intravenous fluids, aluminium hydroxide, calcium gluconate, allopurinol, and dialysis.[1][3]
Surgery
There is no surgical intervention for the management of tumor lysis syndrome.
Primary Prevention
Effective measures for the primary prevention of tumor lysis syndrome include intravenous hydration and administration of either allopurinol or rasburicase.
Secondary Prevention
There are no secondary preventive measures available for tumor lysis syndrome.
Cost-Effectiveness of Therapy
The cost-effectiveness of administration of a singe low dose (3 mg) of rasburicase for tumor lysis syndrome prevention in cancer patients may be superior to the daily intravenous allopurinol.[7]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Cairo MS, Bishop M (2004). "Tumour lysis syndrome: new therapeutic strategies and classification". Br J Haematol. 127 (1): 3–11. doi:10.1111/j.1365-2141.2004.05094.x. PMID 15384972.
- ↑ 2.0 2.1 Nishi HH, Elin RJ (1985). "Three turbidimetric methods for determining total protein compared". Clin Chem. 31 (8): 1377–80. PMID 4017246.
- ↑ 3.0 3.1 Jeha S (2001). "Tumor lysis syndrome". Semin Hematol. 38 (4 Suppl 10): 4–8. PMID 11694945.
- ↑ Wilson FP, Berns JS (2014). "Tumor lysis syndrome: new challenges and recent advances". Adv Chronic Kidney Dis. 21 (1): 18–26. doi:10.1053/j.ackd.2013.07.001. PMC 4017246. PMID 24359983.
- ↑ Locatelli F, Rossi F (2005). "Incidence and pathogenesis of tumor lysis syndrome". Contrib Nephrol. 147: 61–8. doi:10.1159/000082543. PMID 15604606.
- ↑ Coiffier B, Altman A, Pui CH, Younes A, Cairo MS (2008). "Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review". J Clin Oncol. 26 (16): 2767–78. doi:10.1200/JCO.2007.15.0177. PMID 18509186.
- ↑ Patel S, Le A, Gascon S (2012). "Cost-effectiveness of rasburicase over i.v. allopurinol for treatment of tumor lysis syndrome". Am J Health Syst Pharm. 69 (12): 1015–6. doi:10.2146/ajhp110656. PMID 22644973.