Shared insight on the multidisciplinary management of tumor lysis syndrome and how treatment planning may be adjusted after it is identified.
Nicholas James Short, MD: It’s important that all members of the care team, who are potentially going to interact with a patient who has cancer, who might be at risk for tumor lysis syndrome, or who’s undergoing therapy, is aware of recognizing it and also what they need to do. This is an oncologic emergency if it’s severe, and we should think of it like that. This is something that patients can present in the emergency department. They’re presenting symptoms, usually in addition to everything else, but you may get their labs and they may be in spontaneous tumor lysis syndrome. Emergency doctors need to be aware of this and know what to do. They may call an oncologist who’s on call, but as far as temporizing measures and what to look out for, that needs to be done initially in the emergency center.
For institutions that are large teaching hospitals, internists and internal medicine trainees may be the ones dealing with these tumor lysis syndrome that might emerge in a patient undergoing chemotherapy. They may be aware of it before an oncologist. A lot of different people need to be aware. At our institution [The University of Texas MD Anderson Cancer Center], we have a lot of advanced mid-level providers who are the first ones on the ground monitoring patients. They need to be aware, as well as the nurses. That’s why we have a nice algorithm that walks you through in terms of risk stratification [to determine if] this meets the criteria for tumor lysis syndrome. It’s available to those who might interact with this clinical scenario.
Pharmacists are very critical, of course. I’m sure we’re going to talk about some of the medications that can be used for prevention or treatment. They’re also involved with the dosing of that and also whether it’s appropriate to do some of these medications because some of these medications can be expensive. We work with our pharmacist, and we have a formulary that helps us to decide whether it’s appropriate to use these more expensive medications.
Patients who develop severe tumor lysis syndrome—fortunately, it isn’t very common in an era where we’re much more aware of this and have good preventive measures—can develop significant renal dysfunction. Then we need to get our nephrology colleagues involved to manage the electrolyte disturbances that can come with it. It’s important to note that a broad spectrum of providers should be aware of the entity, should be aware of at least identifying it and alerting the oncologist if they’re not an oncologist. A lot of providers can interact with this and can play a major role in managing these patients, certainly when it’s in the acute, more emergent setting.
To go along with that, it’s important to note that tumor lysis syndrome—fortunately, we don’t see a lot of severe cases with the therapies and awareness we have—can cause severe complications. Talk about the outcomes related to tumor lysis and the more severe things that can happen with it.
John L. Reagan, MD: As we talked about before, the maintenance of kidney function is paramount in this business. Renal tubular deposition of the uric acid or the calcium phosphate into the tubules and causing renal dysfunction is the rate-limiting step. That can influence your entire clinical care from then on out. If someone ends up hemodialysis dependent, it limits what you’re able to do. There are some other things too. If you end up developing arrhythmias, that can cause problems and cardiac complications later on. A lot of these are lymphomas that we often use anthracyclines for. Even if you have an AML [acute myeloid leukemia] that gets into tumor lysis trouble, that’s going to run into your anthracycline problems. Other things, such as seizures that develop with the clinical tumor lysis, are going to limit your ability to give any oral medications or any other treatments down the line. These can be damaging effects, which is why we try hard to support people through these episodes. It can also change your management. A lot of times, if we have a patient who’s in an [spontaneous] tumor lysis, you try to get that under control and maybe don’t intervene with any therapies up front.
Or you start with some single-agent cyclophosphamide for debulking or single-agent vincristine. Often a lot of the ALL [acute lymphocytic leukemia] regimens will have steroid preface [doses] built in of prednisone mg/kg [dosing] to get a lot of that tumor bulk down first. Those are important so that you’re not releasing all these toxic substances into the blood all at once. If you can manage…to keep the kidneys functioning, to keep the heart functioning normally, to not end up with complications on top of all this, that can be extremely useful for these patients and keep them on a regimen so they can get their therapies or curative therapies ordered effectively. A big problem we need to watch out for with this is that often we’re dealing with patients for whom we have a real chance of curative therapies. We want to keep them on their treatment regimens and on the treatment regimens that we know can be so beneficial to them.
Transcript edited for clarity.