II. Definition

  1. Acute tumor cell lysis post-Chemotherapy or radiation for tumor debulking
  2. Less commonly, tumor lysis may occur spontaneously with inflammatory cancers

III. Pathophysiology

  1. Massive tumor lysis releases breakdown products
    1. Uric Acid (Hyperuricemia)
    2. Phosphate (Hyperphosphatemia)
    3. Calcium (Hypocalcemia)
    4. Potassium (Hyperkalemia)
  2. Tumor breakdown products overwhelm excretion mechanism
    1. Acute Renal Failure (secondary to Hyperuricemia and Calcium Phosphate crystallization)

IV. Causes: Most common associated tumors

  1. Chemotherapy induction or radiation (within first 5 days)
  2. Acute presentation of undiagnosed rapidly growing tumor
    1. Acute Lymphocytic Leukemia
    2. Lymphoma
    3. Inflammatory Breast Cancer with high rate of proliferation

V. Findings: Presentations related Hyperkalemia, Acute Renal Failure

  1. General symptoms
    1. Nausea or Vomiting
    2. Diarrhea
    3. Lethargy
  2. Cardiac findings
    1. Congestive Heart Failure
    2. Dysrhythmia
    3. Syncope
  3. Neurologic findings
    1. Seizures
    2. Muscle cramps
    3. Tetany

VI. Labs: Chemistry panel

  1. Renal Function tests: Acute Renal Failure
    1. Typically due to Uric Acid and Calcium Phosphate precipitation in the renal tubule
    2. Blood Urea Nitrogen increased
    3. Serum Creatinine increased
  2. Serum bicarbonate or ABG: Metabolic Acidosis
  3. Serum phosphate: Hyperphosphatemia
  4. Serum Potassium: Hyperkalemia
  5. Serum Calcium: Hypocalcemia
  6. Serum Uric Acid
  7. Lactate Dehydrogenase

VII. Diagnostics

VIII. Management

  1. Continuous cardiac monitoring
  2. Hospitalization to intensive care unit
  3. Aggressive Intravenous Fluid hydration
    1. Goal urine output: 100 ml/hour
  4. Monitor elecrolytes every 6 hours
    1. Serum electrolytes including Serum Potassium, Renal Function tests, Serum Calcium, serum phosphate and serum Uric Acid
  5. Manage electrolyte abnormalities
    1. See Hyperkalemia Management
    2. See Hypocalcemia
    3. See Hyperuricemia
    4. See Hyperphosphatemia
    5. See Acute Renal Failure
  6. Hyperuricemia management
    1. Rasburicase (Elitek)
      1. Dose: 0.2 mg/kg in 50 ml Normal Saline over 30 minutes daily for 5-7 days
      2. Preferred in moderate to severe tumor lysis
      3. Recombinant form of urate oxidase (uricase) that converts Uric Acid to allantoin
      4. Allantoin is inactive, much more soluble than Uric Acid, and much more easily renally excreted
      5. Contraindicated in G6PD Deficiency (screen high risk populations)
    2. Allopurinol
      1. Blocks nucleic acid metabolism to Uric Acid
      2. Reduces future Uric Acid production
      3. Does NOT affect Uric Acid already produced
        1. Avoid in ill patients (use rasburicase)
  7. Hyperphosphatemia management
    1. Phosphate Binders (e.g. aluminum hydroxide)
    2. Dialysis
  8. Hyperkalemia Management
    1. See Hyperkalemia
  9. Hypocalcemia management
    1. Hypocalcemia is secondary to Hyperphosphatemia
    2. Do not start Calcium Replacement unless Hyperphosphatemia has corrected
      1. Risk of increased Calcium Phosphate crystals and worsening Acute Renal Failure
      2. Exception: Administer calcium if Hypocalcemia related complications (e.g. Seizures, CHF) or hyperkemia related EKG changes
  10. Alkalinize urine in not recommended in most cases
    1. Not routinely recommended
  11. Hemodialysis
    1. See Hemodialysis for indications

IX. Prevention

  1. Anticipate Tumor Lysis Syndrome
    1. Pretreatment with Intravenous hydration
    2. Pretreatment with Allopurinol

X. References

  1. Aurora and Herbert in Majoewsky (2013) EM:Rap 13(10): 1-4
  2. Shelby (2015) Crit Dec Emerg Med 29(6): 2-8
  3. Higdon (2006) Am Fam Physician 74:1873-80 [PubMed]
  4. Zuckerman (2012) Blood 120(10): 1993-2002 [PubMed]

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Ontology: Tumor Lysis Syndrome (C0041364)

Definition (NCI_CTCAE) A disorder characterized by metabolic abnormalities that result from a spontaneous or therapy-related cytolysis of tumor cells.
Definition (NCI_NCI-GLOSS) A condition that can occur after treatment of a fast-growing cancer, especially certain leukemias and lymphomas (cancers of the blood). As tumor cells die, they break apart and release their contents into the blood. This causes a change in certain chemicals in the blood, which may cause damage to organs, including the kidneys, heart, and liver.
Definition (NCI) A condition of metabolic abnormalities that result from a spontaneous or therapy-related cytolysis of tumor cells. Tumor lysis syndrome typically occurs in aggressive, rapidly proliferating lymphoproliferative disorders. Burkitt lymphoma and T cell acute lymphoblastic leukemia are commonly associated with this syndrome. Metabolic abnormalities include hyperuricemia, lactic acidosis, hyperkalemia, hyperphosphatemia and hypocalcemia and may result in renal failure, multiple organ failure, and death.
Definition (MSH) A syndrome resulting from cytotoxic therapy, occurring generally in aggressive, rapidly proliferating lymphoproliferative disorders. It is characterized by combinations of hyperuricemia, lactic acidosis, hyperkalemia, hyperphosphatemia and hypocalcemia.
Concepts Disease or Syndrome (T047)
MSH D015275
ICD9 277.88
ICD10 E88.3
SnomedCT 277605001
English Syndrome, Tumour Lysis, Syndromes, Tumor Lysis, Syndromes, Tumour Lysis, Tumor Lysis Syndromes, Tumour Lysis Syndrome, Tumour Lysis Syndromes, Syndrome, Tumor Lysis, TUMOUR LYSIS SYNDROME, TUMOR LYSIS SYNDROME, Tumor Lysis Syndrome, Tumor Lysis Syndrome [Disease/Finding], tumour lysis syndrome, tumor lysis syndrome (diagnosis), Tumor lysis syndrome, Tumour lysis syndrome, Tumor lysis syndrome (disorder), tumor lysis syndrome
Portuguese SINDROME DE LISE TUMORAL, Síndrome de lise tumoral, Síndrome de Lise Tumoral
Italian Sindrome da lisi tumorale, Sindrome da lisi di cellule tumorali
Spanish Síndrome de lisis tumoral, síndrome de lisis tumoral (trastorno), síndrome de lisis tumoral, Síndrome de lisis del tumor, Síndrome de Lisis Tumoral
Swedish Tumörlyssyndrom
Japanese シュヨウホウカイショウコウグン, 腫瘍融解症候群, 腫瘍崩壊症候群, 腫瘍溶解症候群
Czech syndrom lýzy nádoru, Syndrom nádorového rozpadu
Finnish Tuumorilyysioireyhtymä
French SYNDROME DE LYSE TUMORALE, Syndrome de lyse tumorale
German TUMORLYSESYNDROM, Tumorlysesyndrom, Tumorlyse-Syndrom
Polish Zespół lizy nowotworu
Hungarian Tumor lysis syndroma
Norwegian Tumorlysesyndrom, Tumorlyse, Tumor lysissyndrom
Dutch tumorlysissyndroom, Syndroom, tumorlysis-, Tumorlysissyndroom