Jarett L. Feldman and Matthew J. Matasar
Definition
TLS is the metabolic abnormalities a/w spontaneous &/or tx-induced cell death that can be potentially fatal in certain situations.
4 key electrolyte abnormalities are:
• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia
• Hyperuricemia
Cairo and Bishop Classification System for TLS (Br J Haematol 2004;127:3)
Lab TLS: (Abnormality in ≥2 of the following when assessed w/in 3 d before or 7 d after the initiation of cytotoxic Rx)
• UA >8 mg/dL or 25% increase from baseline
• Potassium >6 mEq/L or 25% increase from baseline
• Phosphate >4.5 mg/dL or 25% increase from baseline
• Ca <7 mg/dL or 25% decrease from baseline
Clinical TLS: (Lab TLS + 1 or more of the following clinical abnormalities)
• Increased serum Cr (1.5× the ULN)
• Cardiac arrhythmia or sudden death
• Seizure
Common Malignancies Associated with a High Risk of Developing TLS in Adult Patients
• Acute leukemias (eg, AML & ALL)
• High-grade lymphomas such as Burkitt lymphoma & DLBCL. (Of note, indolent lymphomas rarely cause TLS)
Risk Factors: (Br J Haematol 2010;149:578; N Engl J Med 2011;364:1844)
Common factors a/w TLS are:
• High burden of disease (such as a bulky tumor, extensive met or BM involvement)
• Impaired renal function & nephrotoxins
• High proliferation rate of the CA cells
• Sn of the CA cells to tx & intensity of initial anticancer Rx
• Volume depletion, acidic urine, HoTN
Monitoring
• Monitoring UOP is key along w/maintaining an appropriate fluid balance
• Telemetry is routinely used in certain situations
• Common labs include: UA, phosphate, potassium, Cr, Ca & LDH
• High-risk pts could be monitored in ICU w/frequent measurements of electrolytes, Cr & UA levels
• Intermediate- or low-risk pts require lab monitoring ever 8–12 h & daily respectively
Prophylaxis (DeVita, Hellman, and Rosenberg’s cancer: Principles & practice of oncology 9th ed. Lippincott Williams & Wilkins, 2011; Br J Haematol 2011;154:3)
Ppx is key:
Ppx tx options include the following.
• IV hydration: Usually w/NS, rate depends on clinical situation but for high-risk pts recommended 2500–3000 mL/m2/d or obtain a UOP of 2 mL/kg/h
• Urinary alkalinization (controversial)
• Allopurinol &/or rasburicase Rx (rasburicase in high-risk pts only)
Management (J Clin Oncol 2008;28:16)
Hyperkalemia:
• Clinical s/s:
Asx, cardiac dysrhythmia or ECG changes, muscle cramps, paresthesias, nausea, vomiting, diarrhea & sudden death
• Tx Options:
Mod. & asx, >6 mmol/L:
Sodium polystyrene sulfonate & avoid IV & oral potassium
Sev. (>7 mmol/L) &/or symptomatic:
Sodium polystyrene sulfonate, avoid IV & oral potassium, Ca gluconate (100–200 mg/kg) IV for life-threatening arrhythmias, regular insulin (0.1 Unit/kg IV) + D25 (2 mL/kg) IV, Na bicarbonate (1–2 mEq/kg IV push), loop diuretics, inh β-agonists & in sev. cases dialysis.
Hyperphosphatemia:
• Clinical s/s:
Asx, acute renal failure, 2° hypocalcemia
• Tx Options:
Sevelamer hydroxide, Ca carbonate (should not be used in pts w/elevated Ca), lanthanum carbonate & aluminum hydroxide p.o. 15 mL (50–150 mg/kg/24 h) q6h & sev. cases might require dialysis (Avoid IV phosphate administration during TLS)
Hypocalcemia:
• Clinical s/s:
Asx, NM irritability (including tetany, paresthesias, muscle twitching or cramping, laryngospasm or bronchospasm), cardiac dysfunction (including dysrhythmia, HF), mental status changes (including confusion, delirium, & hallucinations), seizure & sudden death
• Tx Options:
Correct hyperphosphatemia & in symptomatic cases Ca gluconate 50–100 mg/kg IV administered slowly w/ECG monitoring
Hyperuricemia:
• Clinical s/s:
Asx, acute renal failure
• Tx Options:
Allopurinol vs. Rasburicase & in sev. cases HD
Allopurinol vs. Rasburicase:
