Tumour lysis syndrome.

Tumour lysis syndrome (TLS) represents a critical oncological emergency characterized by extensive tumour cell breakdown, leading to the swift release of intracellular contents into the systemic circulation, outpacing homeostatic mechanisms. This process results in hyperuricaemia (a by-product of intracellular DNA release), hyperkalaemia, hyperphosphataemia, hypocalcaemia and the accumulation of xanthine. These electrolyte and metabolic imbalances pose a significant risk of acute kidney injury, cardiac arrhythmias, seizures, multiorgan failure and, rarely, death. While TLS can occur spontaneously, it usually arises shortly after the initiation of effective treatment, particularly in patients with a large cancer cell mass (defined as ≥500 g or ≥300 g/m2 of body surface area in children). To prevent TLS, close monitoring and hydration to improve renal perfusion and urine output and to minimize uric acid or calcium phosphate precipitation in renal tubules are essential. Intervention is based on the risk of a patient of having TLS and can include rasburicase and allopurinol. Xanthine, typically enzymatically converted to uric acid, can accumulate when xanthine oxidases, such as allopurinol, are administered during TLS management. Whether measurement of xanthine is clinically useful to optimize the use of allopurinol or rasburicase remains to be determined.

Características clínicas de pacientes con sospecha de síndrome de lisis tumoral. Servicio de Medicina Interna. Hospital General Universitario Dr. Luis Gómez López / Clinical characteristics of patients with suspected tumor lysis syndrome. Internal Medicine Service. General University Hospital Dr. Luis Gómez López

El síndrome de lisis tumoral (SLT) es una complicación potencialmente letal provocada por la liberación masiva de ácidos nucleicos, potasio y fosfato hacia la circulación sistémica lo cual se asocia a graves trastornos del metabolismo hidroelectrolítico. Se realizó una revisión retrospectiva de historias clínicas con el objetivo de describir las características clínicas de los pacientes con sospecha de SLT que ingresaron al Servicio de Medicina Interna del Hospital General Universitario Dr. Luis Gómez López durante el lapso 2017-2018. El 50% de los pacientes tenían una edad comprendida entre 51 y 70 años, siendo el 65% de sexo femenino. Los canceres más frecuentemente encontrados fueron el cáncer de mama (29%), cáncer gástrico (15%) y el linfoma no Hodgkin (12%). Todos los pacientes presentaron al menos tres de las manifestaciones clínicas asociadas al SLT entre las cuales se encuentran náuseas, vómitos, anorexia, debilidad, calambres, hiperreflexia, oliguria, anuria, hematuria, hipotensión, convulsiones y deshidratación. El 46% de los pacientes presentaron hiperpotasemia, mientras que 36% mostraron hipocalcemia y 18% hiperfosfatemia. El 76% de los pacientes cursaron con una creatinina > 1,4 mg/dl. El diagnóstico definitivo de SLT no fue posible realizarlo en ninguno de los pacientes incluidos en este estudio debido a la falta de estudios paraclínicos necesarios para satisfacer los criterios según los lineamientos internacionales(AU)

Tumor lysis syndrome (TLS) is a potentially lethal complication due to massive release of nucleic acids, potassium and phosphate into the systemic circulation which is associated with severe hydroelectrolitic metabolic disorders. A retrospective review of clinical charts was performed in order to describe clinical characteristics of patients with possible TLS that were admitted to the Servicio de Medicina Interna of the Hospital General Universitario Dr. Luis Gómez López during the period 2017-2018. The results show that 50% of patients were between 51 and 70 years old and 65% were female. Breast cancer (29%), stomach cancer (15%) and Non-Hodgkin lymphoma (12%) were more frequent in patients with possible TLS. All patients showed at least three of the clinical features commonly associated with TLS such as nausea, vomiting, anorexia, weakness, cramps, hyperreflexia, oliguria, anuria, hematuria, hypotension, convulsion and dehydration. 46% of patients had hyperkalemia, 36% hypocalcemia and 18% hyperphosphatemia. Creatinine levels > 1,4 mg/dl were seen in 76% of patients. Definitive diagnosis of TLS was not possible in any of the patients included in this study due to the lack of laboratory studies required according to international guidelines(AU)

[Recommendations for tumor lysis syndrome management]. / Recomendaciones para el manejo de la lisis tumoral.

The tumor lysis syndrome represents a potentially lethal complication caused by the massive release of nucleic acids, potassium and phosphate into the circulation as a result of the lysis of neoplastic cells, which are characterized by a rapid proliferation capacity and high sensitivity to drugs. This may occur spontaneously prior to the start of treatment, becoming worse after the initiation of chemotherapy. It presents a high mortality; its prevention continues being the most important therapeutic measure. The clinical picture is characterized by the existence of hydroelectrolytic metabolism disorders, in particular hyperkalemia, hyperphosphatemia and hyperuricemia and by the appearance of an acute renal lesion. Adequate therapeutic intervention involves intravenous hydration and measures to prevent or correct metabolic alterations. This article proposes guidelines to follow both in the diagnostic stage and in the treatment of this complication.

El síndrome de lisis tumoral representa una complicación potencialmente letal provocada por la liberación masiva de ácidos nucleicos, potasio y fosfato hacia la circulación como resultado de la lisis de células neoplásicas, las cuales se caracterizan por una rápida capacidad de proliferación y alta sensibilidad a fármacos. Esto puede ocurrir de forma espontánea antes del inicio del tratamiento y agravarse luego de haberse iniciado la quimioterapia. Presenta una alta mortalidad. Su prevención continúa siendo la medida terapéutica más importante. El cuadro clínico se caracteriza por la existencia de trastornos del metabolismo hidroelectrolítico, en particular, hipercalemia, hiperfosfatemia e hiperuricemia y por la aparición de una lesión renal aguda. Una adecuada intervención terapéutica implica hidratación intravenosa y medidas para prevenir o corregir las alteraciones metabólicas. En este artículo, se proponen lineamientos para seguir tanto en la etapa diagnóstica como en el tratamiento de esta complicación.

[Tumor lysis syndrome]. / Síndrome de lisis tumoral.

Tumor lysis syndrome (SLT) is a rare and potentially fatal entity. It represents an oncological emergency. It can be diagnosed by its clinical presentation and also by laboratory results. In most cases it is presented as a complication of the chemotherapeutic treatment of oncohematological diseases with large tumor mass. Less frequently, a syndrome of spontaneous tumor lysis has been described, or secondary to the use of corticosteroids, hydroxyurea and radiotherapy. In its most severe forms it may require hospitalization in intensive care units and invasive therapeutic measures such as hemodialysis. We report four cases of SLT with unusual presentation characteristics admitted to our Medical Research Institute.

El síndrome de lisis tumoral (SLT) es una entidad poco frecuente y potencialmente fatal. Representa una emergencia oncológica. Puede diagnosticarse por su forma de presentación clínica y también por los resultados de laboratorio. En la mayoría de los casos se presenta como complicación del tratamiento quimioterapéutico de enfermedades oncohematológicas con gran masa tumoral. Con menor frecuencia se ha descrito un síndrome de lisis tumoral espontáneo, o secundario al uso de corticoides, hidroxiurea y radioterapia. En sus formas más graves puede requerir internación en unidades de terapia intensiva y medidas terapéuticas invasivas como la hemodiálisis. Comunicamos cuatro casos de SLT con características de presentación inusual internados en nuestro Instituto de Investigaciones Médicas.

Síndrome de lisis tumoral / Tumor lysis syndrome

El síndrome de lisis tumoral (SLT) es una entidad poco frecuente y potencialmente fatal. Representa una emergencia oncológica. Puede diagnosticarse por su forma de presentación clínica y también por los resultados de laboratorio. En la mayoría de los casos se presenta como complicación del tratamiento quimioterapéutico de enfermedades oncohematológicas con gran masa tumoral. Con menor frecuencia se ha descrito un síndrome de lisis tumoral espontáneo, o secundario al uso de corticoides, hidroxiurea y radioterapia. En sus formas más graves puede requerir internación en unidades de terapia intensiva y medidas terapéuticas invasivas como la hemodiálisis. Comunicamos cuatro casos de SLT con características de presentación inusual internados en nuestro Instituto de Investigaciones Médicas.

Tumor lysis syndrome (SLT) is a rare and potentially fatal entity. It represents an oncological emergency. It can be diagnosed by its clinical presentation and also by laboratory results. In most cases it is presented as a complication of the chemotherapeutic treatment of oncohematological diseases with large tumor mass. Less frequently, a syndrome of spontaneous tumor lysis has been described, or secondary to the use of corticosteroids, hydroxyurea and radiotherapy. In its most severe forms it may require hospitalization in intensive care units and invasive therapeutic measures such as hemodialysis. We report four cases of SLT with unusual presentation characteristics admitted to our Medical Research Institute.

A Case Report of Atezolizumab Induced Tumor Lysis Syndrome.

BACKGROUND Advanced urothelial carcinoma has been associated with poor prognosis due to high resistance to chemotherapy and radiation until immunotherapeutic agents, such as atezolizumab, emerged as an option and have shown improved survival. However, atezolizumab is associated with side effects, which were mainly autoimmune. In this case study, we report on a rare case of atezolizumab-induced tumor lysis syndrome. CASE REPORT A 67-year-old female with a primary diagnosis of metastatic urothelial carcinoma who presented to the emergency department with generalized weakness associated with nausea and vomiting 8 days after her first cycle of atezolizumab. Laboratory values showed hyperphosphatemia, hyperuricemia, hypocalcemia, and acute kidney injury consistent with tumor lysis syndrome. CONCLUSIONS In our report, we highlight tumor lysis syndrome as a potential reaction to atezolizumab; a condition that requires prophylaxis and close laboratory monitoring.

Tumour lysis syndrome. / Síndrome de lisis tumoral.

Tumour lysis syndrome (TLS) is a life-threatening emergency characterised by a massive cytolysis with the release of intracellular electrolytes, nucleic acids, and metabolites into the circulation. TLS comprises laboratory derangements (hyperuricaemia, hyperkalaemia, hyperphosphataemia, and hypocalcaemia) responsible for acute kidney injury. In patients with hematologic malignancies after cytotoxic therapy or spontaneously and also in advanced solid tumours. Assessment of disease specific risk level for TLS in patients receiving anti-tumoural therapy is essential for early diagnosis. Prophylaxis is the mainstay of management of TLS. It is important to routinely initiate a risk-adapted prophylactic strategy to correct metabolic alterations and preserve renal function. High and intermediate risk patients and patients with established TLS should be managed with multidisciplinary medical care in a hospital unit to receive monitoring and medical care. Renal replacement therapy should be considered in patients with refractory TLS.

Opioid toxicity with underlying tumour lysis syndrome in a patient with CMML: a diagnostic and therapeutic challenge.

Use of strong opioids like morphine as analgesics for painful conditions in haematological malignancies is a challenging task. We report a unique case of chronic myelomonocytic leukaemia presenting with opioid toxicity overlapping with tumour lysis syndrome. The patient was on hydroxyurea-based chemotherapy for the primary disease. She was receiving oral morphine for abdominal pain due to splenomegaly. She was brought to the emergency in unresponsive state with pinpoint pupils. Opioid overdose leading to unconsciousness was suspected as the first diagnosis. Further workup revealed a final diagnosis of tumour lysis syndrome overlapping with opioid overdose. The patient was ventilated and started on naloxone infusion, and supportive measures for managing tumour lysis were added. The patient gradually improved and was extubated on the fifth day of ventilation. This case presents several learning points for the treating physician. Haematological malignancies have a dynamic course of disease with waxing and waning tumour burden during the course of chemotherapy. This fact should be kept in mind when prescribing strong opioids like morphine on outpatient basis to these patients. Massive tumour cell lysis during the course of chemotherapy may precipitate tumour lysis syndrome and may lead to renal dysfunction which makes the patient susceptible to morphine-related adverse effects. Pain physician should keep a watch for therapy-related adverse effects to avoid diagnostic and therapeutic dilemma associated with coexisting features of these two fatal conditions.

Oncologic Metabolic Emergencies.

Cancer and its therapies may lead to several metabolic emergencies that emergency providers (EPs) should be well-versed in identifying and managing. With prompt recognition and treatment initiation in the emergency department, lives can be saved and quality of life maintained. Most oncologic metabolic emergencies occur in advanced cancer states, but some follow initiation of treatment or may be the presenting syndrome that leads to the cancer diagnosis. This article reviews the 2 most emergent oncologic metabolic diagnoses: tumor lysis syndrome and hypercalcemia of malignancy. A discussion on associated cancers and conditions, pathogenesis and pathophysiology, and management recommendations is included.

Post-cytokine-release Salt Wasting as Inverse Tumor Lysis Syndrome in a Non-cerebral Natural Killer-cell Neoplasm.

The pathogenesis of cerebral/renal salt-wasting syndrome remains unknown. We herein present a case of salt-wasting syndrome with a natural killer-cell neoplasm without cerebral invasion. A 78-year-old man with hemophagocytic syndrome received two cycles of chemotherapy that did not induce tumor lysis syndrome, but repeatedly caused polyuria and natriuresis. The expression of tumor necrosis factor-α in the neoplasm led us to hypothesize that an oncolysis-induced cytokine storm may have caused renal tubular damage and salt wasting. Our theory may explain the pathogenic mechanism of cerebral/renal salt-wasting syndrome associated with other entities, including cerebral disorders, owing to the elevation of cytokine levels after subarachnoid hemorrhage.

Tumor Lysis Syndrome: A Unique Solute Disturbance.

Tumor lysis syndrome (TLS) is a life-threatening disorder that is an oncologic emergency. Risk factors for TLS are well-known, but the current literature shows case descriptions of unexpected acute TLS. Solid tumors and untreated hematologic tumors can lyse under various circumstances in children and adults. International guidelines and recommendations, including the early involvement of the critical care team, have been put forward to help clinicians properly manage the syndrome. Advanced practice nurses may be in the position of triaging and initiating treatment of patients with TLS, and need a thorough understanding of the syndrome and its treatment.

Serum Uric Acid Exhibits Inverse Relationship with Estimated Glomerular Filtration Rate.

BACKGROUND: In this study, we investigated the relationship between serum uric acid (SUA) and renal function in a unique patient cohort wherein SUA levels fluctuate during the course of standard care. METHODS: Correlation coefficients between SUA and serum creatinine (SCr) and kinetic estimated GFR (KeGFR) were retrospectively investigated in acute myeloid leukemia (AML) patients, and statistically significant and clinically relevant determinants were studied in multiple regression models. RESULTS: One hundred and twenty-six patients were included in the analysis. Baseline SUA was associated with an increased risk for acute kidney injury (AKI; OR 1.27, 95% CI 1.1-1.5, p = 0.003) and laboratory tumor lysis syndrome (OR 1.26, 95% CI 1.1-1.5, p = 0.005). Prophylactic uric acid-lowering therapy and hydration resulted in lower SUA values from baseline in 88.1% of the patients, the lowest values were observed on post-induction day 1 (20.4% reduction). Significant linear correlations were observed between SUA and SCr (r = 0.35, p < 0.001) values with a significant inverse correlation between SUA and KeGFR on day 1 (r = -0.33, p < 0.001) that persisted through day 4. By subgroup analysis, patients with primary AML (r = -0.49, p < 0.001), baseline SUA >5.5 mg/dl (r = -0.41, p = 0.002) and baseline eGFR >60 ml/min/1.73 m2 (r = -0.51, p < 0.001) demonstrated robust relationships between SUA and KeGFR. The relationship was more robust when the groups were combined (primary AML plus baseline SUA >5.5 mg/dl plus baseline eGFR >60 ml/min/1.73 m2, r = -0.52, p < 0.001). CONCLUSION: The demonstration of linear relationship between SUA and SCr and inverse relationship between SUA and KeGFR reinforces the emerging translational physiological evidence regarding the role of uric acid in AKI.

Preventing Tumor Lysis Syndrome: Two Case Studies of Unexpected Outcomes.

BACKGROUND: Tumor lysis syndrome (TLS) is a potentially fatal complication in patients with large, rapidly proliferating tumor cell cancers that may occur after chemotherapy. Patients with TLS are complicated to treat and often have an unpredictable trajectory. OBJECTIVES: The purpose of this article is to report two cases with unusual clinical manifestations and unexpected outcomes during cancer treatment and to share best practices for this situation. METHODS: The authors described details from two unusual cases and outlined lessons learned. The authors described a newly developed clinical order set (protocol) to support optimal care for patients at risk for TLS. FINDINGS: Implementing best practices, the order set prompts early identification of TLS risk and provides step-by-step guidance to eliminate or control TLS.

Hypersensitivity and tumor lysis syndrome associated with cetuximab treatment: should we be afraid?

The majority of the chemotherapy agents in use today cause various infusion reactions, from mild flushing to life-threatening events. The frequency of the reported hypersensitivity reactions induced by cetuximab varies between 3% and 22%. It is recommended in the literature to stop the infusion and replace cetuximab with panitumumab in case of hypersensitivity reactions observed during the treatment of colon cancer. Tumor lysis syndrome (TLS) may occur in colorectal cancers with heavy tumor load. Tumor lysis syndrome may be life-threatening. In our patient with widespread bone and liver metastases, treatment continued with cetuximab as a combination therapy with irinotecan in spite of the hypersensitivity and TLS led to a complete treatment response. The complete response observed after 3 months through continued therapy in our patient may present an example supporting treatment with cetuximab in spite of severe reactions.