Tumer lysis syndrom

1. SALALE UNIVERSITY COLLEGE OF HEALTH
SCIENCE DEPARTMENT OF ADULT HEALTH NURSE
MASTERS PROGRAM
Prepared by: Azazhu Abate, ID NO: 177/2015
Submitted to: Mr Tadele K. (BSC, MSc, Ass/t Prof)
Date: July 2023
Fitche, Ethiopia

2. Outline
• Introduction Tumor lysis syndrome
• Pathophysiology of Tumor lysis syndrome
• Clinical features of TLS
• Risk factors for TLS
• Diagnosis of TLS
• Prevention of TLS
• Treatment of TLS
• Prognosis of TLS

3. Objectives
At the end of seminar presentation, students will
be able to:
• Define the tumor lysis syndrome
• Discuss signs and symptoms of TLS
• Informed with risk factors of TLS
• Familiar with diagnosis, prevention and treatment

4. Tumor lysis syndrome
• Introduction: Tumor lysis syndrome is a group
of metabolic abnormalities that can occur as a
complication from the treatment of cancer,
where large amounts of tumor cells are killed
off from the treatment, releasing their contents
into the bloodstream.

5. Cont…
• TLS is oncologic emergency which is manifested
by severe electrolyte abnormalities such as
release of large amounts of-
 Potassium
 phosphate, and
 nucleic acids into the systemic circulation as a
result of acute renal failure.

6. Cont…
• It is potentially life-threatening conditions that
happen within hours after cancer treatment
initiation of those fast-growing cancers,
especially cancers of the blood.
• It is most common in patients diagnosed with
leukemia .

7. Cont…
• It can also be seen in high-grade lymphomas
after the initiation of aggressive chemotherapy.
• Other solid tumors that can cause tumor lysis
syndrome are hepatoblastoma, neuroblastoma.

8. Pathophysiology
• Pathogenesis of TLS involves massive blood
tumor cell lysis resulting in the release of large
amounts of potassium, phosphate, and uric acid.
• Deposition of uric acid and calcium phosphate
crystals in the renal tubules may lead to acute
renal failure

9. Cont…
• This is often exacerbated by concomitant
intravascular volume depletion.
• The kidney normally excretes these products,
and consequently preexisting renal failure
exacerbates the metabolic derangements of
tumor lysis syndrome.

10. Clinical features
• Hyperkalemia: K is mainly an intracellular ion. High
turnover of tumor cells leads to spill of potassium into
the blood.
• Symptoms usually do not manifest until levels are
high (> 6.5 mmol/L) [normal 3.5–5.0 mmol/L] and
they include palpitations, cardiac conduction
abnormalities, and arrhythmias muscle weakness or
paralysis

11. Cont…
• Hyperphosphatemia: phosphates are also
predominantly intracellular.
• It causes acute kidney injury in tumor lysis
syndrome, because of deposition of calcium
phosphate crystals in the kidney parenchyma.

12. Cont…
• Hypocalcaemia: Because of the excess
phosphatemia, calcium is precipitated to form
calcium phosphate, leading to hypocalcaemia.
• Symptoms: tetany, paresthesias, muscle cramp
and weakness, sudden changes in mental
status, Parkinson like movement disorders,
papilledema

13. Cont…
• Hyperuricemia: massive cell death and
nuclear breakdown generates large
quantities of nucleic acids.
• Of these, the purines (adenine and
guanine) are converted to uric acid via the
purine degradation pathway and excreted
formation of urate crystals in the kidney.

14. Risk factors
• Risk factors for tumor lysis syndrome depend on
 Different characteristics of the patient,
The type of cancer, and
The type of chemotherapy used.

15. Cont…
• Tumor characteristics: Tumors with a high cell
turnover rate, rapid growth rate and poorly
differentiated tumors tend to be more associated
with the development of tumor lysis syndrome.
• Example: Burkitt's lymphoma), Non-Hodgkin
Lymphomas (NHL), acute lymphoblastic
leukemia (ALL)

16. Cont…
• Patient characteristics: Certain patient-related
factors can affect the development of clinical
tumor lysis syndrome.
• These factors include elevated baseline
serum creatinine, kidney failure, dehydration,
and other issues affecting urinary flow or the
acidity of urine

17. Con…
• Chemotherapy characteristics: Chemo-sensitive
tumors, such as lymphomas, carry a higher risk for
the development of tumor lysis syndrome.
• Those tumors that are more responsive to a
chemotherapy agent carry a higher TLS risk.
• precipitating medication regimen includes
combination chemotherapy

18. Diagnosis
• TLS should be suspected in patients with large tumor
burden who develop acute kidney failure along with
hyperuricemia (> 15 mg/dL) or hyperphosphatemia
(> 8 mg/dL).
• The hyper secretion of uric acid can be detected with
a high urine uric acid - creatinine ratio > 1.0,
compared to a value of 0.6–0.7 for most other causes
of acute kidney failure.

19. Cont…
Diagnosis of TLS is based on two definitions
1. Cairo-Bishop definition: In 2004, Cairo and
Bishop defined a classification system for tumor
lysis syndrome
2. Howard definition: In 2011, Howard proposed a
refinement of the standard Cairo-Bishop definition
of TLS accounting for 2 limitations

20. Cairo-Bishop definition
1. Laboratory tumor lysis syndrome
abnormality in two or more of the following,
occurring within three days before or seven days
after chemotherapy.
uric acid > 8 mg/dL or 25% increase
potassium > 6 meq/L or 25% increase
phosphate > 4.5 mg/dL or 25% increase
calcium < 7 mg/dL or 25% decrease

21. Cont…
2. Clinical tumor lysis syndrome: laboratory
tumor lysis syndrome plus one or more of the
following:
– increased serum creatinine (1.5 times upper limit
of normal)
– cardiac arrhythmia or sudden death
– seizure
• A grading scale (0–5) is used depending on the
presence of lab TLS, serum creatinine,
arrhythmias, or seizures.

22. Howard definition
• Two or more electrolyte laboratory
abnormalities must be present simultaneously to
be considered related to TLS.
• In fact, some patients may present with one
abnormality, but later another one may develop
that is unrelated to the TLS (e.g., hypocalcaemia
associated with sepsis).

23. Cont…
• A 25% change from baseline should not be
considered a criterion since such increases are
rarely clinically important unless the value is
already outside the normal range.
• Moreover, any symptomatic hypocalcaemia
should constitute clinical TLS.

24. Prevention
• TLS prevention include aggressive hydration,
control of hyperuricemia with allopurinol and
rasburicase medications, and close monitoring of
electrolyte abnormalities.
• Allopurinol and rasburicase (which inhibits uric
acid production) works by preventing the
formation of uric acid following tumor cell lysis.

25. Treatment
Disturbances
1. Hyperkalemia
2. Hypocalcaemia
3. Hyperphosphatemia
4. Uremia
5. Renal failure
Management
 Sodium polystyrene
 calcium gluconate
 Aluminum hydroxide
 IV hydration; IV rasburicase
 Dialysis

26. Prognosis
• The rate of mortality from tumor lysis syndrome
may vary widely depending on the type of
underlying malignancy. However, the occurrence
of acute kidney injury is concerning given the
high mortality that is generally associated with it.

27. Summary
• Tumor lysis syndrome is a potentially fatal metabolic
condition that occurs most frequently in patients with
rapidly proliferating, bulky, chemo sensitive tumors.
• TLS is oncologic emergency which is known by severe
electrolyte abnormalities such as release of large
amounts of Potassium, phosphate, and nucleic acids
into the systemic circulation as a result of acute renal
failure.

28. References
1. Davidson MB, Thakkar S, Hix JK, Bhandarkar ND, Wong A, Schreiber
MJ (April 2004). "Pathophysiology, clinical consequences, and
treatment of tumor lysis syndrome". The American Journal of
Medicine. 116 (8): 546–554.
2. Belay Y, Yirdaw K, Enawgaw B (2017). "Tumor Lysis Syndrome in
Patients with Hematological Malignancies". Journal of
Oncology. 2017: 9684909.
3. Darmon M, Malak S, Guichard I, Schlemmer B (September
2008). "Acute tumor lysis syndrome: a comprehensive
review". Revista Brasileira De Terapia Intensiva. 20 (3): 278–285.

29. Thanks!