Management of Tumor Lysis Syndrome - Episode 6

Prevention Strategies and Monitoring in TLS


Anthony R. Mato, MD, MSCE: The NCCN [National Comprehensive Cancer Network] has helpful guidelines for the management of tumor lysis syndrome [TLS]. Just as a reminder, TLS is manifested by the laboratory abnormalities of hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia, which can lead to clinical symptoms like renal dysfunction or cardiac arrhythmias. There are certain risk factors for TLS, including the tumor type. Burkitt lymphoma is a classic example.

Other risk factors for TLS are the bulk of disease—including the size of the lymph nodes or the elevation of the white blood cell count or lymphocyte count—pre-existing comorbidities such as renal dysfunction or renal involvement by tumor, or hyperuricemia which may be unrelated or occurring prior to even the start of therapy. Once TLS occurs, we need to think about how this condition can be managed appropriately.

Of course, appropriate prophylaxis with uric acid—lowering agents or with IV [intravenous] fluids in monitoring is the best measure to prevent this from occurring. But should TLS occur, you need to deal with the individual abnormalities.

Mainstays of therapy as per the NCCN include rigorous hydration, additional management strategies for hyperuricemia—for example, increasing the dose of allopurinol or providing uric acid—lowering agents like recombinant urate oxidase—more frequent monitoring of electrolytes so that you can prevent or identify whether a laboratory event is becoming a clinical event, and then potentially changing the acuity of observation—from home to outpatient, outpatient to inpatient, or inpatient to an ICU. Also, you would involve appropriate specialists as needed. If there’s an arrhythmia or very high electrolyte disturbances, this would involve colleagues from the cardiovascular division. If there’s a concern or the need for hemodialysis, or if aggressive measures are needed for managing electrolyte abnormalities, this would involve my colleagues from the renal medicine service.

This is all very nicely summarized by the NCCN and can be helpful for managing patients with acute leukemias for non-Hodgkin lymphomas.

Michael R. Bishop, MD: Risk stratification plays an extremely important role in the management and prevention of TLS. Patients who are deemed a low-risk population, with low tumor burden, a low degree of proliferation, and using agents that are not highly cytotoxic, are more easily managed with just hydration and close observation alone. For the patients who are at intermediate and high risk, those are the patients who are going to need more aggressive treatment and preventive measures such as the use of allopurinol, rasburicase, and aggressive hydration. Depending on the risk stratification, that will determine how often they need to be monitored and in what setting.

Transcript Edited for Clarity