Tumor Lysis Syndrome

20 Aug

BASICS:

Oncologic emergency caused by tumor cell lysis (duh)

-Look for tumor lysis syndrome in patients with recent initiation of chemotherapy or radiation, or in cancers with extremely high proliferative rates (Lymphoma and Leukemias). 

-can occur spontaneously as well, most documented in the lymphomas and leukemias, so do not discount the presence of TLS in patients without recent initiation treatment.

-Manifested by both end organ damage and electrolyte abnormalities

 

Electrolyte Abnormalities: caused by release of intracellular contents

Hyperkalemia caused by the release of intracellular potassium stores can cause arrhythmias

Hyperphosphatemia is often caused.  Phosphorous stores in cancer cells is up to 4 times the normal storage amount found in normal cells- with cell lysis hyperphosphatemia is common.  Calcium can bind to the phosphate forming calcium phosphate precipitation, leading to hypocalcemia.

 

End Organ Damage

-Release of nucleic acids leads to their catabolism and eventual production of uric acidHyperuricemia can lead to crystal precipitation and deposition in the renal tubules leading to acute renal failure. 

-Precipitation of calcium-phosphate crystals in the renal tubules can also lead to acute renal failure.

 

TREATMENT:

Aggressive IV hydration

-Rasburicase is often used to treat hyperuricemia- it is the enzyme urate oxidase which catalyzes the oxidation of uric acid to a safer to excrete renally compound allantoin.

Hyperkalemia can be treated similar to normal managementD50 plus insulin, beta agonists, sodium bicarbonate, and sodium-potassium exchange resins.  HOWEVER calcium administration is generally avoided unless there is evidence of arrhythmia/EKG changes or neurological involvement (seizures), because it can contribute to further production of calcium phosphate crystals and worsen the renal injury.

 

Submitted by J. Grover.

 

References: Uptodate.  “Tumor Lysis Syndrome:  Definition, Pathogenesis, Clinical Manifestations, Etiology, and Risk Factors.”  5/30/2012. Uptodate.  “Tumor Lysis Syndrome:  Prevention and Treatment.” Tintinalli 7th Edition.  Chapter 18, pp. 1512-1513.; picture

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