AnaLYSIS of the Nurse’s Role in Assessment and Treatment of Tumour Lysis Syndrome (TLS)

Presented by:Adrianna DeCastro BScN, RN - Stronach Regional Health Centre

Disclosures

• I have received an honorarium for this presentation• Medical Oncology Outpatient Clinic• Some slide credits to clinicaloptions.com

Objectives

• Define Tumour Lysis Syndrome (TLS)• Who is at Risk?• Signs and Symptoms of TLS• Nursing Management

What is TLS?

• Oncologic emergency• Rapid breakdown of cancer cells results in intracellular release

Ø Uric Acid Ø Phosphorus Ø Potassium

What is TLS?

• Rapid breakdown = buildup in the blood stream• Causes metabolic abnormalities • TLS has two phases • The oncology RN plays a pivotal role in recognizing TLS and promptly

intervenes • Early intervention = better patient outcomes!

Categories of TLS

Laboratory TLS

Clinical TLS

Lysis of tumour cells

clinicaloptions.com

Risk Factors for TLSBulky Tumours• Large tumour mass• Organ infiltration• Bone marrow involvement

(leukemia's are bulky)

Highly Proliferative Tumours• LDH is a marker• Chemosensitive tumours• Burkitt lymphoma• Lymphoblastic lymphoma• Acute leukemia

Howard S, et al. Leuk Lymph. 2006;47:782-785.

https://www.cancernetwork.com/sites/default/files/cn_import/1837774.png

Cardiac Symptoms

• Hypertension• Dysrhythmias• Cardiac arrest

de Souza Institute

Neurological Symptoms

• Fatigue/lethargy• Weakness• Memory loss• Altered mental status• Muscle cramps• Tetany• Seizures• Paresthesias (numbness and tingling)

de Souza Institute

GI Symptoms

• Anorexia• Nausea & vomiting• Abdominal cramps• Diarrhea

de Souza Institute

GU Symptoms

• Flank pain• Oliguria• Anuria• Renal failure• Acidic urine

de Souza Institute

Signs & Symptoms of TLS

PUCK

Signs & Symptoms of TLS

PUCKHyperPhosphatemia

Signs & Symptoms of TLS

Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome

Signs & Symptoms of TLS

PUCK

HyperUricemia

Signs & Symptoms of TLS

Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome

Signs & Symptoms of TLS

PUCK

HypoCalcemia

Signs & Symptoms of TLS

Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome

Signs & Symptoms of TLS

PUCKHyperKalemia

Signs & Symptoms of TLS

Held-warmkessel, J. (2012, August 27). A Patient With Tumor Lysis Syndrome. Retrieved January 29, 2020, from https://www.cancernetwork.com/oncology-nursing/patient-tumor-lysis-syndrome

Signs & Symptoms of TLS

PUCKHyperPhosphatemia

HyperUricemia HypoCalcemia

HyperKalemia

Hyperkalemia:release of intracellular

potassium

Hyperphosphatemia:release of intracellular

phosphates

Cardiac arrhythmia

PO3-

Ca2+

4

PO3-

Ca2+Uric acid crystals

Acute renal failure

Release of DNA(nucleic acids)

Hypoxanthine

Xanthine

Xanthine oxidase

Calcium phosphateprecipitates

4

2. Cammalleri L, Malaguarnera M. Rasburicase represents a new tool for hyperuricemia in tumor lysis syndrome and in gout. Int J Med Sci. 2007;4:83-93.

Management of TLS

• Allopurinol • One to two days prior to starting therapy and up to seven days post-

chemo • Hydrate, Hydrate, Hydrate!• Two to three litres of water per day• Cardiac monitoring and dialysis for patients severe clinical TLS

TLS ManagementMinimal Risk Low Risk Intermediate Risk High Risk Clinical TLS

No prophylaxis indicated

Prophylaxis:hydration ±allopurinol

Daily lab tests

Prophylaxis:hydration + allopurinol; consider rasburicase

Lab tests every 8-12 hrs

Prophylaxis:hydration +rasburicase

Lab tests every 6-8 hrs

Cardiac monitoring

Prophylaxis:hydration +rasburicase

Lab tests every 4-6 hrs

Cardiac monitoring in ICU

Howard SC, et al. N Engl J Med. 2011;364:1844-1854. clinicaloptions.com

Case Study• Mr. R is to be treated with Venetoclax 20mg OD x 7 DAYS• Starting labs WBC=44.9Cr=116Lymph=30.9• Returned 6 hours later for repeat labs• Allopurinol 300mg OD started 5 days prior

Case Study Cont’d• Labs @ 16:00 WBC=36.3 (4.0-11.0)Uric Acid= 279 (170-460)Phos=1.27 (0.83-1.48)Cr=112 (46-92)K+=4.9 (3.5-4.2)Calcium=2.28• Mr. R was hydrating orally 1.5-2 litres daily

Case Study Cont’d24 hours later• Cr= 117 (46-92)• Uric Acid= 320 (170-460)• WBC= 34 (4.0-11.0)• K+=4.9 (3.5-4.2)• Phos=1.17 (0.83-1.48)• Calcium=2.28• Returned 48 hours later with stable labs

Ramp-Up Dosing Schedule: Venetoclax

Cancer Care Ontario Requires TLS Prophylaxis based on Tumour Burden

Cancer Care Ontario Requires TLS Prophylaxis based on Tumour Burden

Cancer Care Ontario Requires TLS Prophylaxis based on Tumour Burden

Summary

• Define tumour lysis • Detecting signs and symptoms• Management • Venetoclax case study

Thank You!

• adecastro@southlakeregional.org• Feel free to contact me if you have any questions