Synopsis
Estimate lysis risk before anticancer treatment, prevent avoidable metabolic injury and reverse hyperkalaemia, phosphate accumulation, urate burden and renal failure before arrhythmia, seizure or death.
- TLS is rapid release of tumour-cell potassium, phosphate and nucleic acid; phosphate lowers calcium and purines become urate, threatening heart, brain and kidney.
- Risk is determined before treatment from cancer type and sensitivity, burden, LDH, tumour count, baseline urate, renal function, hydration, obstruction and planned therapy.
- First-line baseline and serial tests are potassium, phosphate, calcium, urate, creatinine, bicarbonate and LDH with ECG and strict fluid balance when risk is important.
Key red flags
ECG change, muscle weakness, bradycardia or ventricular arrhythmia with rising potassium requires immediate hyperkalaemia treatment before formal TLS criteria are completed.
Weakness, paraesthesia, bradycardia, broad QRS, absent P waves or ventricular arrhythmia is an immediate resuscitation problem.
Investigation priorities
Identify the biochemical syndrome and immediately dangerous electrical effect.
Management branches
A responsive malignancy is about to receive systemic therapy, corticosteroid prephase, radiotherapy or another rapid tumour-reducing intervention.
- Classify tumour and patient risk from diagnosis, burden, LDH, tumour count, renal reserve, urate, hydration, obstruction and planned treatment.
- Correct volume depletion, stop avoidable nephrotoxins and potassium or phosphate supplements and choose ambulatory, ward or higher-acuity monitoring appropriate to risk.
Key medicines
AllopurinolGive 300 mg orally once daily, or 100 mg three times daily, commonly starting 24 to 48 hours before tumour-reducing treatment and continuing through the defined lysis-risk period, with renal dose adjustment.
RasburicaseGive rasburicase 0.2 mg/kg intravenously once daily over 30 minutes for up to 7 days, with actual duration determined by risk, tumour response and serial urate under the current BSH and product protocol.