Tumour Lysis Syndrome

Question 1

What is TLS?

Answer 1

When tumour cells breakdown and release the contents into the bloodstream, leading to significant electrolyte imbalances

Question 2

When is TLS more likely to occur?

Answer 2

Poorly differentiated lymphoma’s (Burkitt’s lymphoma, high grade NHL)
Leukaemia - especially ALL and AML
Fast growing tumours - liver, breast, SCLC

Question 3

What are the risk factors for TLS? (8 points)

Answer 3

Large tumour burden
LDH > 150
Age
Increased tumour sensitivity to chemo
Increased bone marrow infiltration
Pre-existing renal disease
Dehydration
Concurrent use of nephrotoxic drugs

Question 4

What symptoms does TLS present with?

Answer 4

Non-specific:
Nausea / vomiting
Headache
Lethargy
Reduced urine output
Syncope
Chest pain
Palpitations

Question 5

What are two clinical signs of hypocalcaemia?

Answer 5

Trousseau’s sign - BP cuff inflated > flexion of wrist and hand
Chvostek’s sign - involuntary contraction of muscles innervated by the facial nerve on percussion

Question 6

What blood tests should be ordered for suspected TLS?

Answer 6

FBC
U&Es
Bone profile
Uric acid
LDH

Question 7

What is the laboratory criteria for the diagnosis of TLS?

Answer 7

Uric acid >/ 476 micromol/L or 8mg/dL
Potassium >/ 6mmol/L
Phosphate >/ 1.45 mmol/L
Calcium < 1.75 mmol/L
Or 25% increase / decrease for the above, respectively

Question 8

What is the clinical criteria for TLS?

Answer 8

Two or more of the laboratory results plus one of the following:
- Creatinine 1.5x baseline
- Cardiac arrhythmias
- Seizure
- Sudden death

Question 9

What is the definition for laboratory TLS diagnosis!

Answer 9

Laboratory results with at least two of the following occurring between 3 days before chemotherapy or 7 days after initiation of cancer treatment

Question 10

What is given as a preventative measure for TLS?

Answer 10

Allopurinol for low to intermediate risk patients
Rasburicase is considered if allopurinol does not reduce serum uric acid
Rasburicase is used for high risk patients

IV saline given for two days before treatment is started and bloods 1-2/ day (intermediate), 3-4/day (high risk)

Question 11

What is the management for TLS?

Answer 11

IV fluids
Daily weights
Bloods six-hourly after TLS diagnosis
ECG and consider cardiac monitor

Question 12

How do you manage the electrolyte imbalances?

Answer 12

Hyperuricaemia - Rasburicase 3-7 days or allopurinol max dose
Hyperkalaemia - calcium gluconate, actrapid, glucose 25g IV
Hyperphosphataemia - phosphate binding agents
Hypocalcaemia - calcium gluconate

Question 13

What are the complications of TLS?

Answer 13

AKI - Uric acid and calcium excess
Cardiac arrhythmias
Lactic acidosis - chemotherapy-induced apoptosis
Seizures - hypocalcaemia and/or hyperphosphataemia