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Oncology Exam 4
Frei Tumor Lysis Syndrome I
| Question | Answer |
|---|---|
| Tumor Lysis Syndrome background: | -Most common disease-related oncologic emergency -Rapid lysis of cells -> release of intracellular contents into bloodstream -Associated with significant morbidity and mortality if not recognized and treated early -Can occur spontaneously or in response to cytotoxic chemotherapy |
| Complications of TLS | pts get lab abnormalities (same process with gout). Calcium phosphate precipitate and lead to pt renal failure |
| Lab abnormalities that can occur with TLS include? | -Hyperuricemia -Hyperkalemia (most abundant cellular cation) -Hyperphosphatemia (tumor cells have 4x more phosphate than normal cells) -Hypocalcemia (get above certain conc. in blood and start binding together and precipitate in kidneys) *Calcium phosphate precipitation contributes to acute renal insufficiency/failure |
| Risk Factors that are disease-related to TLS are? | -Cancer diagnosis Hematologic malignancy > solid tumor (can occur with solid tumors but less common) -Tumor burden Bulky tumor (> 10 cm) WBC > 25 x 109/L Elevated LDH -Proliferation rate -Sensitivity to chemotherapy |
| Risk factors that are patient-related to TLS are? | Dehydration Hypotension Acidosis Pre-existing renal or cardiac disease |
| High risk malignancies of TLS: Hematologic Malignancy--> | -Burkitt's lymphoma -Acute myeloid leukemoa -Acute lymphoblastic leukemia |
| Which of the following is NOT a laboratory abnormality that will seen with TLS? | Hypercalcemia |
| What is the clinical presentation of TLS? | Typically presents 12-72 hours after initiation of cytotoxic chemotherapy OR Spontaneously w/o regard to chemotherapy |
| What classification is used for TLS? | Cairo-Bishop classification |
| Laboratory TLS (LTLS) looks for __ or more metabolic abonormalities within __ days before or __ days after initiation of therapy | 2; 3; 7 |
| ⭐️The laboratory TLS looks at what measurements from baseline? (2 or more metabolic abnormalities within 3 days before or 7 days after initiation of therapy ⭐️ | Potassium ≥ 6 mEq/L OR 25% increase from baseline⭐️ Uric Acid ≥ 8 mg/dL OR 25% increase from baseline⭐️ Phosphorus ≥ 4.5 mg/dL OR 25% increase from baseline⭐️ Calcium ≤ 7 mg/dL OR 25% decrease from baseline⭐️ |
| Aside from the laboratory TLS, the Cairo-Bishop classification also looks at the Clinical TLS (CTLS) where it looks for? *This is a CLINICAL diagnosis | Presence of laboratory TLS plus one or more of the following: -Renal involvement - SCr ≥ 1.5 x ULN Cardiac involvement - Arrhythmia/sudden death Neurologic involvement - Seizure *ULN: upper limit of normal; Adults:1.2 mg/dL |
| Remember the 4 main clinical presentation of TLS which are? | Hyperuricemia (Uric acid crystallization in urine/kidneys) Hyperphosphatemia (Muscle cramps, nausea/vomiting, diarrhea, lethargy, seizures) Hypocalcemia (Occurs when calcium-phosphorus product exceeds 60 mg2/dL2 Muscle cramps, parasthesias, tetany, altered mental status, seizures, hypotension, cardiac arrhythmias) Hyperkalemia ⭐️ (Most serious electrolyte derangement Nausea/vomiting, diarrhea, anorexia, muscle cramps, parasthesias, cardiac arrhtymias) |
| Which of the following meets diagnostic criteria for Lab TLS? | K: 6.2, Phos 4.3, Ca 7.9, Uric acid 8 |
| How can TLS be prevented? Preventative measures should be initiated in patients at intermediate and high risk of TLS | -IV hydration (Preserves renal function Increased renal perfusion Increased glomerular filtration Increased urine output -Anti-hyperuricemic agents Prevent formation of uric acid |
| For prevention measures for TLS, be sure to monitor? | -Baseline labs: electrolytes, uric acid, lactate dehydrogenase (LDH), WBC count, SCr -Frequent monitoring (8-12 hours): Comprehensive metabolic panel (CMP), uric acid, phosphorus, ins/outs -Cardiac monitoring: High risk patients |
| IV hydration for TLS prevention uses and looks at? | -Minimum 2-3 L isotonic IV fluid daily -Urine output goal: 80 to 100 mL/hr -+/- loop diuretics -Monitor volume status closely -Start 24-48 hours prior to initiation of cytotoxic therapy |
| Anti-hyperuricemic agents can be used to prevent the formation of uric acid. What agents are included in this drug class? | Allopurinol; Febuxostat |
| Anti-hyperuricemic agents Xanthine Oxidase Inhibitors: ⭐️Allopurinol drug info? | -100 mg/m2 PO every 8 hours (maximum 800 mg/day⭐️) -Start 2 days prior to chemotherapy -Continue for up to 3 to 7 days afterwards -Long history of use -Requires renal dose adjustment⭐️ -Risk of hypersensitivity reaction HLA*B5801 ⭐️ |
| Anti-hyperuricemic agents Xanthine Oxidase Inhibitors: Febuxostat drug info? | -120 mg PO daily -Start 2 days prior to chemotherapy -Continue for 7 to 9 days afterwards -No renal dose adjustment -No risk of hypersensitivity -Box warning--> risk of CV death⭐️ -$$$ |
| Florence Trial? | Febux vs Allopurinol--> Day 3 started chemo. Blue is Allo; green is Febuxostat. Statisitically sig more than Allopurinol. |
| Anti-hyperuricemic agents – urate oxidase mechanism? | -Rasburicase (recombinant urate oxidase) -Converts uric acid to allantoin (5-10x more soluble than uric acid) -Can decrease existing plasma uric acid quickly (decreases due to conversion) Few adverse effects -Can be used for prevention in high-risk patients -$$$$ - not typically used for prevention due to cost |
| Which pt should be given preventative tx for TLS | A 22 yo female starting tx for newly diagnosed ALL |
| Select the appropriate regimen for TLS prevention | Normal saline IV given at 85 mg/hr +allopurinol 200 mg PO every 8 hours |
| Treatment for TLS: we need to look at? | Laboratory TLS Admission to telemetry or ICU (based on severity of labs) Laboratory monitoring every 6-8 hours Clinical TLS Admission to ICU Laboratory monitoring every 4-6 hours Aggressive IV hydration Urine output goal: 80-100 mL/hr Continuous cardiac monitoring Dialysis should be available if necessary |
| When it comes to treatment, which Anti-hyperuricemic agent cannot be used for Treatment, but can be used for prevention? | Febuxostat *Not recommended for treatment Data lacking for treatment of TLS Data lacking for concomitant use with rasburicase |
| Treatment dose of Anti-hyperuricemic agents Xanthine Oxidase Inhibitors: Allopurinol? | 100 mg/m2 PO every 8 hours (maximum 800 mg/day) Reduces formation for new uric acid |
| Anti-hyperuricemic agents – Rasburicase for the tx of TLS. MOA and monitoring? *golden child for treatment for uric acid and to preserve renal function--> is Rasburicase | Uric acid converted to allantoin (5-10x more soluble than uric acid) Decreases existing plasma uric acid Contraindications: G6PD deficiency⭐️, pregnancy/lactation Monitoring ⭐️Serum uric acid level 4 hours after infusion, then every 6-12 hours until uric acid and LDH normalize ⭐️Sample must be placed on ⭐️ice immediately after collection (to prevent the breakdown of rasburicase of uric acid) |
| Rasburicase vs allopurinol Onset | slow decreases in uric acid over days. trying to prevent formation but trying to take care of what's already there. *dosing of rasburicase is controversial *both can be used together |
| Electrolyte Derangements: Hyperkalemia: Shifting K+ into the cells via? | Insulin regular 10 units IV push + D50W (glucose) 50 mL IV push Albuterol 10-20 mg nebulized over 10 minutes |
| Electrolyte Derangements: Hyperkalemia: Stabilize cardiac myocytes via? | Calcium gluconate 1 g IV push over 5-10 minutes *only if they have EKG changes |
| Electrolyte Derangements: Hyperkalemia: Remove K+ via? | -Furosemide 20-40 mg IV push -Patiromer (Veltassa) 8.4 g PO daily with food at least 6 hrs before or after any other oral medication -Sodium Zirconium Cyclosilicate (Lokelma) 10 g PO TID for up to 48 hours |
| Electrolyte Derangements: Hyperphosphatemia: Fix by? | -Lower dietary phosphate intake -Phosphate binders -Hemodialysis (severe) |
| Electrolyte derangements: Hypocalcemia | -Treatment not recommended for asymptomatic hypocalcemia Monitor closely -Symptomatic hypocalcemia: calcium gluconate 1 g via slow IV, using caution in severe hyperphosphatemia *will not replace unless we have to |
| Summary of TLS: | • Laboratory abnormalities occur secondary to rapid lysis of tumor cells • Usually occurs in response to cytotoxic chemotherapy • Early recognition is key!!! • Highest risk: Burkitt’s lymphoma, ALL, AML • Prevention required in high-risk cancers 24-48 hours prior to start of cytotoxic chemotherapy • Prevention: XO inhibitor + IV fluids • Treatment: allopurinol + rasburicase + IV fluids + correction of electrolytes (as needed) |
Created by:
Xander635
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