Tumor lysis syndrome

Metabolic syndrome caused by the massive release of cellular components during the lysis of malignant cells. This lysis can be spontaneous (30% of cases) or occur during the first course of chemotherapy.

Malignancies at risk are those with a fast tumor doubling rate time, e.g.: non-Hodgkin lymphoma (especially Burkitt lymphoma), all acute leukemias with major hyperleukocytosis, some solid tumors.

Two additional risk factors are:

-        hyperuricemia > 450 µmol/l

-        the presence of oliguria or a pre-existing  renal failure due to either the precipitation of urate or phosphocalcic crystals in the renal tubules, or compression of the urinary tract (by the tumor)

The biological signs are:

-        hyperuricemia > 475 µmol/L

-        hyperkalemia > 6 mmol/L

-        hypocalcemia < 1.75 mmol/L

-        hperphosphoremia > 3mmol/L


Sometimes, an alveolar lung disease or hemostasis disorders (fibrinolysis, DIC) are associated.

Treatment:

-        hyperhydration (except in case of kidney failure or oliguria): If > 10 kg: 200 ml/kg/d of a ¼ glucose 5% and ¾ NaCl 0.9%  mixture.

-        treatment to lower hyperuricemia: urate-oxidase (rasburicase, Fastuterc®): 0.15 to 0.2 mg/kg/day IV in 30 minutes; contraindication in case of G6PD deficiency; possible side effects: respiratory distress, methemoglobinemia

-        diuretics in case of insufficient diuresis

-        alkalization (NaHCO3) only in case of acidosis

-        normalize calcium level only if hypocalcemia is symptomatic

-        extrarenal treatment (dialysis) if persistent hyperkalemia, hyperphosphoremia > 3.2 mmol/L or if [Ca x P] is < 4.6 (in mmol/L)


Anesthetic implications:

-        keep this diagnosis in mind at risk situations: fast tumour growth (biopsy, installation of central catheter)

-        very frequent monitoring of K, P and creatinine blood levels

-        in case of cardiac arrest: to be treated as hyperkalemic until proven otherwise

-        avoid any corticosteroid therapy, including the administration of low doses of dexamethasone as antiemetic, without the advice of a hematologist: cases of hyperkalemic cardiac arrest have been described.


References : 

-         Jabbour E, Ribrag V.
Traitement actuel du syndrome de lyse tumorale.
Revue Méd Interne 2006 ; 26 : 27-32.

-        Farley-Hills E, Byrne AJ, Brennan L, Sartori P.
Tumour lysis syndrome during anaesthesia.
Pediatr Anesth 2001; 11: 233-6.

-        Mc Donnel C, Barlow R, Campisi P, Grant R, Malkin D.
Fatal peri-operative tumour lysis syndrome precipitated by dexamethasone.
Anaesthesia 2008; 63: 652-5.

-        Osthaus WA, Linderkamp C, Bünte C, Jüttner B, Sümpelmann R.
Tumor lysis syndrome with dexamethasone use in a child with leukemia.
Pediatr Anesth 2008; 18:268-70.

-        Sinha R, Bose S, Subramaniam R.
Tumor lysis under anesthesia in a child.
Acta Anaesthesiol Scand 2009; 53: 131-3.


Updated: July 2017