Tumour lysis syndrome

Tumour lysis syndrome (TLS) is an oncological emergency characterised by metabolic and electrolyte abnormalities that can occur after the initiation of any cancer treatment, but can also occur spontaneously.

It is caused by rapid breakdown of large numbers of cancer cells and subsequent release of large amounts of intracellular content into the bloodstream, which overwhelms normal homeostatic mechanisms.

The pathophysiological manifestations of TLS can lead to acute kidney injury, cardiac arrhythmias, seizures, and neuromuscular dysfunction, which can cause considerable morbidity and in some cases death. It can also compromise the clinical management of cancer patients.

Most commonly associated with highly proliferative, bulky, chemosensitive haematological malignancies, particularly high-grade B-cell lymphoid malignancies (e.g., acute lymphocytic leukaemia and Burkitt's lymphoma). However, reports of TLS associated with other malignancies (including solid tumours) are increasing due to advances in cancer treatment.

TLS can be classified as laboratory TLS (defined as the presence of two or more of the following metabolic abnormalities: hyperuricaemia, hyperphosphataemia, hyperkalaemia, or hypocalcaemia) or clinical TLS (defined as laboratory TLS with one or more of the following clinical manifestations: acute kidney injury [i.e., increased serum creatinine], cardiac arrhythmia, seizure, or sudden death).

Early identification of patients at risk of TLS and initiating appropriate preventive management is effective in most patients. Vigorous hydration in combination with hypouricaemic agents constitutes the cornerstone of both prevention and treatment.

Tumour lysis syndrome (TLS) is an oncological emergency characterised by metabolic and electrolyte abnormalities that can occur after the initiation of any cancer treatment, but can also occur spontaneously.[1]Coiffier B, Altman A, Pui CH, et al. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008 Jun 1;26(16):2767-78. http://www.ncbi.nlm.nih.gov/pubmed/18509186?tool=bestpractice.com It is caused by rapid breakdown of large numbers of cancer cells and subsequent release of large amounts of intracellular content (potassium, phosphate, nucleic acids) into the bloodstream, which overwhelms normal homeostatic mechanisms resulting in hyperuricaemia, hyperphosphataemia, hyperkalaemia, and/or hypocalcaemia.

TLS is most commonly associated with highly proliferative, bulky, chemosensitive haematological malignancies, particularly high-grade non-Hodgkin's lymphoma (e.g., Burkitt's lymphoma) and acute lymphoblastic leukaemia.[1]Coiffier B, Altman A, Pui CH, et al. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008 Jun 1;26(16):2767-78. http://www.ncbi.nlm.nih.gov/pubmed/18509186?tool=bestpractice.com [2]Williams SM, Killeen AA. Tumor lysis syndrome. Arch Pathol Lab Med. 2019 Mar;143(3):386-93. https://www.archivesofpathology.org/doi/10.5858/arpa.2017-0278-RS http://www.ncbi.nlm.nih.gov/pubmed/30499695?tool=bestpractice.com However, reports of TLS associated with other types of malignancies (including solid tumours) are increasing due to advances in cancer treatment.[2]Williams SM, Killeen AA. Tumor lysis syndrome. Arch Pathol Lab Med. 2019 Mar;143(3):386-93. https://www.archivesofpathology.org/doi/10.5858/arpa.2017-0278-RS http://www.ncbi.nlm.nih.gov/pubmed/30499695?tool=bestpractice.com [3]McBride A, Westervelt P. Recognizing and managing the expanded risk of tumor lysis syndrome in hematologic and solid malignancies. J Hematol Oncol. 2012 Dec 13;5:75. https://jhoonline.biomedcentral.com/articles/10.1186/1756-8722-5-75 http://www.ncbi.nlm.nih.gov/pubmed/23237230?tool=bestpractice.com [4]Howard SC, Trifilio S, Gregory TK, et al. Tumor lysis syndrome in the era of novel and targeted agents in patients with hematologic malignancies: a systematic review. Ann Hematol. 2016 Mar;95(4):563-73. http://www.ncbi.nlm.nih.gov/pubmed/26758269?tool=bestpractice.com [5]McBride A, Trifilio S, Baxter N, et al. Managing tumor lysis syndrome in the era of novel cancer therapies. J Adv Pract Oncol. 2017 Nov-Dec;8(7):705-20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188097 http://www.ncbi.nlm.nih.gov/pubmed/30333933?tool=bestpractice.com