Have you ever broken a Piñata as part of a celebration before?
The confetti and candies that fell out of the broken Piñata is just so… exciting!
Tumor lysis syndrome (TLS) on the other hand is, well—let’s just say it is less pleasant than breaking a Piñata. It is a condition that occurs when a large number of cancer cells die within a short period, releasing their contents into the blood—like a broken Piñata releasing its contents in the party.
How does TLS affect the body?
TLS is a medical emergency commonly seen among cancer patients. When cancer cells break down in the body as a result of cancer treatment, they release uric acid, potassium and phosphate into the blood. However, if such breakdown happens too fast, the levels of these three substances rise quicker than the kidneys can remove them.
As a result, excess uric acid, potassium and phosphate can accumulate in the body and lead to a bunch of health problems. This causes TLS. Excess phosphorus can “sop up” calcium, leading to low levels of calcium in the blood. Changes in blood levels of uric acid, potassium, phosphorus, and calcium can affect the functioning of several organs, especially the kidneys, and also the heart, brain, muscles, and gastrointestinal tract.
Signs and symptoms of TLS
General signs and symptoms of TLS include:
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Abdominal pain
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Nausea
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Vomiting
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Diarrhea
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Anorexia (lack of appetite)
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Lethargy
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Hematuria (blood in urine)
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Heart failure
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Cardiac dysrhythmias (irregular heartbeat)
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Seizures
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Muscle cramps
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Tetany (involuntary contraction of muscles that usually results from low calcium levels in the blood)
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Syncope
If TLS is left untreated, kidney failure or even sudden death can occur.
Who develops TLS?
Image credit to: JAMA Oncol. 2018;4(6):895. doi:10.1001/jamaoncol.2018.0613
Not all cancer patients are at equal risk of developing TLS. TLS are more likely to happen in patients with a large “tumor burden” of cancer cells and/or tumors that typically have rapidly dividing cells, such as acute leukemia or high-grade lymphoma, as well as tumors that are highly responsive to therapy. Although TLS can also happen spontaneously before a cancer treatment, it is more common within a week of starting cancer treatment.
TLS is not limited to patients receiving traditional chemotherapy; it can also occur in patients receiving steroids, hormonal therapy, targeted therapy, or radiation therapy. Patients who are dehydrated and those with existing kidney impairment are at higher risk of developing TLS.
Prevention of TLS
Because TLS can have life-threatening consequences, prevention is crucial. The common strategies of preventing TLS are:
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Intravenous (IV) hydration with saline — This helps to improve blood flow in the kidneys and promote more urination, thereby reducing risk of uric acid and calcium phosphate formation in the kidney. IV hydration also makes the urine more alkaline (increases pH), which increases uric acid solubility and promotes its removal from the body.
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Allopurinol — It is a medication that is used to decrease uric acid production in the body. It is also commonly used for the treatment of gout. However, allopurinol cannot reduce the pre-existing high uric acid level that is already present in the blood. The usual allopurinol dose in adults is 100 mg/m2 every eight hours (maximum 900 mg per day). The dose should be reduced in patients with kidney problems.
Patients at high risk of TLS undergo bloodwork and clinical monitoring before and during therapy to ensure early diagnosis if it develops.
How is TLS treated?
TLS can still happen even with preventive strategies. The treatment is similar to its prevention, which involves giving IV fluids and allopurinol. Patients may require admission to the intensive care unit. Blood tests are repeated frequently to assess electrolyte levels and kidney damage, and the heart rhythm and urine output are closely monitored. When electrolyte imbalances do occur, the levels are carefully corrected using medications and fluids. Some patients with severe kidney injury may require temporary hemodialysis.
A word from DOC2US
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