Tumor lysis syndrome resident survival guide: Difference between revisions

Jump to navigation Jump to search
No edit summary
Line 53: Line 53:
ULN: Upper limit of normal
ULN: Upper limit of normal


==Management==
==Prevention of TLS==
Shown below is an algorithm summarizing the approach to <nowiki>[[disease name]]</nowiki>.
Prevention of tumor lysis syndrome is of prime importance because once it is established, it is very difficult to treat and life threatening.
Shown below is an algorithm summarizing the approach to <nowiki>[[tumor lysis syndrome]]</nowiki>.
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | A01 |A01= }}  
{{familytree | | | | | | | | | A01 | | | A01= Identify patients at risk of TLS}}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | | |,|-|-|-|+|-|-|-|.| | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | | | B01 | | B02 | | B03 | | | B01= <div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;"> '''Low Risk Disease (LRD):'''<br>
{{familytree | | | |!| | | | | | | | | |!| }}
----
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
❑ Solid tumors <br> ❑ [[Multiple myeloma]] <br> ❑ Indolent [[Non-Hodgkin's lymphoma]] <br>❑[[Hodgkin's lymphoma]]<br> ❑ [[AML]] with WBC count ≤25,000 cells/μL and LDH < 2× ULN <br> ❑ [[CLL]] with WBC count < 50,000 cells/μL, treated only with [[alkylating agents]] <br> ❑ [[CML]]<br>
{{familytree | |,|-|^|.| | | | | | | | |!| }}
</div>|B02=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;"> '''Intermediate Risk Disease (IRD):'''<br>
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
----❑ Bulky or advanced stage solid tumors <br> ❑ [[Plasma cell leukemia]] <br> ❑ Stage III/IV [[Non-Hodgkin's lymphoma]] with LDH > 2xULN <br> ❑[[AML]] with WBC count ≤25,000 cells/μL and LDH > 2× ULN OR [[AML]] with WBC count 25,000-100,000 cells/μL <br> ❑ [[CLL]] treated with [[fludarabine]] or [[rituximab]] or CML with WBC count > 50,000 cells/μL <br> ❑ [[ALL]] with WBC < 100,000 cells/μL and LDH > 2xULN<br>❑ [[Burkitt's lymphoma]] stage I/II with LDH < 2x ULN<br>
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
❑[[Lymphoblastic lymphoma]] stage I/II with LDH < 2x ULN
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
</div>|B03=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''High Risk Disease (HRD):'''<br>
{{familytree | | | | | | | | | | |!| | | | |!| }}
----
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
❑ [[AML]] with WBC count > 100,000 cells/μL <br> ❑ [[ALL]] with WBC >100,000 cells/μL AND/OR LDH > 2xULN <br> ❑[[Burkitt's lymphoma]] stage III/IV with LDH ≥ 2x ULN <br> ❑ [[Lymphoblastic lymphoma]] stage III/IV with LDH ≥ 2x ULN <br>❑ IRD with renal dysfunction<br>❑ IRD with uric acid, potassium or phosphate above ULN<br>
</div>}}
 
 
{{familytree | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | C01 | | C02 | | C03 | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}
{{familytree/end}}



Revision as of 01:37, 19 January 2014


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Definition

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 blood. It is a life threatening condition and an oncologic emergency. Metabolic complications include hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia and hyperuricosuria.

Causes

Life Threatening Causes

Tumor lysis syndrome resulting from any cause is a life threatening condition and needs immediate management.

Common Causes

Commonly tumor lysis syndrome is precipitated by chemotherapy in patients with hematologic malignancies.

Classification

Cairo and Bishop classified and graded TLS as laboratory tumor lysis syndrome (LTLS) and clinical tumor lysis syndrome (CTLS).

Cairo and Bishop Definition for Laboratory Tumor Lysis Syndrome (LTLS)

LTLS is considered to be present if 2 or more of the following serum abnormalities are present within 3 days or 7 days after cytotoxic therapy.

Element Value Change from baseline
Uric acid ≥476 μmol/L or 8 mg/dL 25 % increase
Potassium ≥6 mmol/L or 6mg/L 25 % increase
Phosphorus ≥2.1 mmol/L for children
≥1.45 mmol/L for adults
25 % increase
Calcium ≤1.75 mmol/L 25% decrease

Cairo and Bishop Definition and Grading for Clinical Tumor Lysis Syndrome (CTLS)

Clinical tumor lysis syndrome is said to be present if LTLS is present plus 1 or more of the following clinical correlations:

Complication Grade
0 1 2 3 4 5
Creatinine ≤1.5×ULN 1.5×ULN >1.5-3.0×ULN >3-6×ULN >6×ULN Death
Cardiac arrhythmia None Intervention not indicated Medical intervention indicated,
but not urgently
Controlled with a device or
symptomatically and incompletely
controlled medically
Life threatening Death
Seizure None - One well controlled generalized seizure OR
infrequent multiple focal motor seizures
not affecting activities of daily living
poorly controlled seizure disorder,
seizure with altered consciousness
Status epilepticus,
intractable epilepsy
Death

ULN: Upper limit of normal

Prevention of TLS

Prevention of tumor lysis syndrome is of prime importance because once it is established, it is very difficult to treat and life threatening. Shown below is an algorithm summarizing the approach to [[tumor lysis syndrome]].


 
 
 
 
 
 
 
 
Identify patients at risk of TLS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low Risk Disease (LRD):

❑ Solid tumors
Multiple myeloma
❑ Indolent Non-Hodgkin's lymphoma
Hodgkin's lymphoma
AML with WBC count ≤25,000 cells/μL and LDH < 2× ULN
CLL with WBC count < 50,000 cells/μL, treated only with alkylating agents
CML

 
Intermediate Risk Disease (IRD):

❑ Bulky or advanced stage solid tumors
Plasma cell leukemia
❑ Stage III/IV Non-Hodgkin's lymphoma with LDH > 2xULN
AML with WBC count ≤25,000 cells/μL and LDH > 2× ULN OR AML with WBC count 25,000-100,000 cells/μL
CLL treated with fludarabine or rituximab or CML with WBC count > 50,000 cells/μL
ALL with WBC < 100,000 cells/μL and LDH > 2xULN
Burkitt's lymphoma stage I/II with LDH < 2x ULN

Lymphoblastic lymphoma stage I/II with LDH < 2x ULN

 
High Risk Disease (HRD):

AML with WBC count > 100,000 cells/μL
ALL with WBC >100,000 cells/μL AND/OR LDH > 2xULN
Burkitt's lymphoma stage III/IV with LDH ≥ 2x ULN
Lymphoblastic lymphoma stage III/IV with LDH ≥ 2x ULN
❑ IRD with renal dysfunction
❑ IRD with uric acid, potassium or phosphate above ULN

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
{{{ C01 }}}
 
{{{ C02 }}}
 
{{{ C03 }}}
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

References


Template:WikiDoc Sources