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Assess for tumor lysis syndrome using Cairo-Bishop criteria
Normal: 3.5-7.2 mg/dL | TLS: >8 or 25% increase
Normal: 3.5-5.0 mEq/L | TLS: >6 or 25% increase
Normal: 2.5-4.5 mg/dL | TLS: >4.5 or 25% increase
Normal: 8.5-10.5 mg/dL | TLS: <7 or 25% decrease
| Parameter | Laboratory TLS Criteria | Clinical TLS |
|---|---|---|
| Uric Acid | >8 mg/dL or 25% increase | Lab TLS + Organ dysfunction |
| Potassium | >6 mEq/L or 25% increase | |
| Phosphate | >4.5 mg/dL or 25% increase | |
| Calcium | <7 mg/dL or 25% decrease | |
| Lab TLS Definition: 2 or more abnormalities within 3 days before or 7 days after chemotherapy | Seizure, arrhythmia, or AKI (Cr ≥1.5× ULN) | |
Tumor Lysis Syndrome (TLS) is a life-threatening oncologic emergency that occurs when large numbers of cancer cells die rapidly, releasing their intracellular contents into the bloodstream. This massive cell breakdown overwhelms the body's ability to eliminate these substances, leading to dangerous metabolic abnormalities.
When tumor cells lyse, they release:
TLS most commonly occurs with rapidly proliferating, chemotherapy-sensitive tumors:
Symptoms result from metabolic derangements:
Prevention is crucial and risk-stratified:
Management escalates based on severity:
Two main options for uric acid management:
TLS most commonly occurs 12-72 hours after initiating chemotherapy (especially the first cycle), but can occur spontaneously in rapidly growing tumors before treatment or up to 7 days after starting therapy. High-risk patients require monitoring starting before treatment.
Yes, spontaneous TLS can occur in rapidly proliferating tumors with high cell turnover, particularly Burkitt lymphoma and acute leukemias with very high white blood cell counts. Spontaneous TLS indicates aggressive disease biology and high risk.
Rasburicase produces hydrogen peroxide when breaking down uric acid. Patients with G6PD deficiency cannot adequately metabolize hydrogen peroxide, leading to severe hemolytic anemia and methemoglobinemia. Always screen high-risk populations (African, Mediterranean, Middle Eastern ancestry) for G6PD before rasburicase.
No, avoid treating asymptomatic hypocalcemia, especially in the presence of hyperphosphatemia. Calcium administration can cause calcium-phosphate precipitation in tissues and kidneys, worsening renal function. Only treat if patient has symptomatic hypocalcemia (seizures, tetany, prolonged QT).
Urinary alkalinization with sodium bicarbonate was previously recommended to prevent uric acid precipitation but is no longer routinely used. It can worsen calcium-phosphate precipitation. With modern rasburicase use, alkalinization is generally avoided. Maintain neutral pH with adequate hydration.
Continue prophylaxis (hydration, allopurinol) until the risk period has passed - typically 3-7 days after chemotherapy depending on tumor type and response. Lab monitoring can be spaced out as values stabilize. High-risk patients may need prophylaxis for subsequent cycles.
Dialysis indications include: severe hyperkalemia unresponsive to medical therapy (K >6.5-7), severe azotemia, oliguria/anuria, volume overload, symptomatic uremia, or symptomatic hypocalcemia with concurrent hyperphosphatemia. Early nephrology consultation is essential for high-risk patients.
While rare, TLS can occur with solid tumors, particularly those that are bulky, rapidly growing, or highly chemosensitive (small cell lung cancer, germ cell tumors, breast cancer, melanoma with high tumor burden). Case reports exist for many solid tumor types, so maintain awareness in appropriate clinical contexts.