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Tumour Lysis Syndrome

This section describes diagnosis and initial management of tumour lysis syndrome (TLS).

Introduction

TLS is a potentially fatal syndrome characterised by a group of metabolic derangements caused by the release of cellular components into the blood after rapid lysis of malignant cells. This is most often seen at the initial treatment of a number of high grade malignant haematological disorders and results from the instigation of treatment. However, in a small number of cases, patients can present with TLS prior to the initiation of any chemotherapy. Patients at highest risk of TLS include those with high cell-count leukaemias, lymphoblastic lymphoma, bulky diffuse large B cell and Burkitt lymphoma, but less commonly, some non-haematological malignancies may present with TLS e.g. germ cell tumours or small cell lung cancer. Patients with TLS often have a high lactate dehydrogenase (LDH) level.

Features of Tumour Lysis Syndrome

Seek urgent Haematology review for patients presenting with clinical and/or laboratory features of TLS. 

Clinical features of TLS reflect associated metabolic abnormalities
  • Acute oliguria and renal failure
  • Cardiac rhythm disturbance
  • Confusion and seizures
  • Nausea and vomiting
  • Muscle cramps and tetany
Laboratory definition of TLS

Laboratory TLS (LTLS) can be defined using the Cairo and Bishop* definition. The presence of two or more of the following abnormalities within 3 days prior to and up to 7 days after the initiation of cancer treatment is indicative of TLS:

  • Uric acid ≥ 0.476mmol/l (476micromol/l) or 25% increase from baseline.
  • Potassium ≥ 6mmol/l or 25% increase from baseline
  • Phosphate ≥1.45mmol/l or 25% increase from baseline
  • Calcium ≤ 1.75mmol/l or 25% decrease from baseline
  • Creatinine ≥ 50% increase from baseline

N.B. Spontaneous TLS prior to the initiation of any chemotherapy is associated with hyperuricaemia but frequently not with hyperphosphataemia.

*Cairo, M.S. & Bishop, M. (2004). Tumour lysis syndrome: new therapeutic strategies and classification. BrJHaem, 127(1), 3-11. Adapted with permission 2024.

Management

See the West of Scotland Cancer Network (WoSCAN) guideline on the Prophylaxis and Management of Tumour Lysis Syndrome in Adults which provides information on the definition of TLS, risk factors, assessment and treatment. The guideline is accessible via the WoSCAN intranet site (NHS network access required) / Guidelines and Protocols section / Supportive Care subsection.

The electrolyte disturbance section of the handbook provides dosing advice but should only be referred to once Haematology advice has been obtained. Treatment of established TLS should be only under the supervision of a haematologist (see Appendix 6 for contact details).

The following bloods are required while monitoring patients with TLS:

  • Urea and Electrolytes
  • Bone profile
  • LDH
  • Urate

Please refer to the WoSCAN guideline for further information on frequency of monitoring and seek guidance from haematology.

Note: Urate samples taken whilst patients are on rasburicase should reach the laboratory within 30 minutes and be interpreted with caution.

 

Guideline reviewed: October 2024

Page updated: November 2024