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Tumor lysis syndrome (TLS) is a serious metabolic disturbance caused by the death of cancer cells during cancer treatment and the release of their intracellular components into the bloodstream. TLS is characterized by the rapid development of hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia, and is potentially life-threatening.Risk factors include a large tumor size, tumors with rapid cell division and growth, hematologic cancers such as acute leukemia or high-grade (aggressive) lymphoma, and tumors with a high sensitivity to chemotherapy.
Patients with high levels of lactate dehydrogenase (greater than 1,000 U/L) and impaired renal function are also at risk, as are some patients with mediastinal tumors. Several chemotherapy agents, including cytarabine, cisplatin, etoposide, and paclitaxel, are associated with TLS.
Based on the presence of certain risk factors, patients can be placed into low-, intermediate-, or high-risk categories:
* High-risk patients are those with Burkitt lymphoma, lymphoblastic lymphoma, or B-cell acute lymphoblastic leukemia.
* Patients at intermediate risk have diffuse large-cell lymphoma or another type of rapidly growing cancer.
* Low-risk patients have indolent (slow-growing) lymphoma or another slowly proliferating cancer.
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How TLS Develops
In a highly proliferative cancer such as acute leukemia, some leukemia cells die before treatment as part of their life cycle. If many of them lyse and die, TLS may develop before cancer treatment even begins. However, most cancer cells in the bloodstream and bone marrow of patients with acute leukemia are destroyed with chemotherapy.
As cells lyse and die, they release intracellular components into the bloodstream. Large amounts of potassium and phosphate are released, along with purine nucleic acids.
The signs and symptoms of TLS may occur as early as a few hours after the start of chemotherapy, but are more common 24 to 48 hours after treatment begins. The mortality rate for patients who develop TLS is about 18%.
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Diagnosis:
Tumor lysis syndrome is diagnosed by lab tests or by clinical signs and symptoms. The Cairo-Bishop Grading System, used to classify and grade TLS, defines lab abnormalities in serum uric acid, potassium, and phosphorus levels as a 25% increase over baseline and a 25% decrease from baseline in serum calcium levels.
This system considers lab value changes that occur in patients from three days before to seven days after chemotherapy begins. The clinical abnormalities classified by this system are graded based on severity and include age-adjusted serum creatinine, cardiac dysrhythmias, and seizures.
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