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Table of Contents
Causes
Symptoms
Diagnosis
Treatment
Prevention
Tumor lysis syndrome (TLS) occurs when a large amount of cancer cells die at once—either spontaneously or as the result ofcancer treatment—and release their contents into the bloodstream. This can cause a potentially fatal imbalance inelectrolyteslike potassium, calcium, and phosphate and dangerously high levels of waste products like uric acid in the blood.TLS can cause potentially devastating symptoms like irregular heartbeats, seizures,acute kidney failure, and coma. It most often occurs with blood cancers but can happen with certain solid tumor cancers as well. The treatment is primarily focused on reducing uric acid levels and normalizing electrolyte levels with medications and hydration.This article describes the causes and symptoms of tumor lysis syndrome, including who is most at risk. It also explains how TLS is treated and prevented.FatCamera/E+/Getty ImagesWhy Does Tumor Lysis Syndrome Occur?Tumor lysis syndrome occurs when a large number of cancer cells die suddenly. As tumor cells die (lyse) and break open, their spilled contents—including potassium, phosphate, and uric acid—are released in massive amounts into the bloodstream.This spillage ultimately leads to the following metabolic abnormalities:High blood levels of potassium (hyperkalemia)High blood levels of phosphate (hyperphosphatemia)High blood levels of uric acid (hyperuricemia)High levels of phosphate, in turn, bind to calcium to form calcium phosphate crystals, resulting in a severe drop in blood calcium levels (hypocalcemia).The massive death of tumor cells also triggers the release of inflammatory proteins calledcytokines. This can lead to a whole-body inflammatory response known as a"cytokine storm" which can cause multi-organ failure.Cancers Linked to TLSTumor lysis syndrome most often occurs with certain blood cancers and a small handful of solid tumor cancers as well. Tumors vulnerable to TLS are typically aggressive (fast-growing) and highly responsive tochemotherapy.The cancers most commonly associated with TLS are:Aggressivenon-Hodgkin lymphomas (NHL)likeBurkitt’s lymphomaAcute lymphoblastic leukemia (ALL), also known as acute lymphocytic leukemiaAcute myeloid leukemia (AML)Small cell lung cancer (SCLC)TLS is less commonly associated with:Chronic lymphocytic leukemia (CLL)Anaplastic large cell lymphoma (ALCL)NeuroblastomaBreast cancerSoft tissue sarcomasMerkel cell carcinoma (MCC)MelanomaResearchers have found that more than one in four children with acute lymphoblastic leukemia will develop TLS after undergoing cancer treatment.Other Risk FactorsTumour lysis syndrome typically occurs at the start of chemotherapy. It can happen within a few hours of treatment but is most often seen 48 to 72 hours after chemotherapy starts.TLS can also occur spontaneously, but this is rare.In addition to chemotherapy, risk factors for TLS include:High white blood cell countHigh blood uric acid levelsHigh blood potassium levelsHigh blood phosphate levelsA high “tumor burden” (meaning a high number of cancer cells or a large tumor)Late-stage cancerPre-existing kidney diseaseDehydrationWhat Are the Symptoms of Tumor Lysis Syndrome?Electrolytes are electrically charged minerals that the body needs to function normally, regulating everything from heartbeats and muscle contractions to eye and brain function. Having too many or too few as a result of TLS can disrupt these functions and lead to symptoms like:Heart palpitationsIrregular heartbeatsNumbness, burning, or tingling sensations in the hand or feetChanges in mental status, including sudden outburstsUncontrollable body movementsFlickering, blurred, or double visionMuscle weakness or paralysisSeizuresHigh uric acid levels can be particularly harmful, leading to a condition calledmetabolic acidosisthat can quickly become fatal if left untreated. Symptoms include:Fatigue and weaknessHeadacheRapid heartbeatsAnxietySweatingLong, deep breathingNausea and vomitingLoss of appetiteA fruity-smelling breathConfusionComaMetabolic acidosis along with the deposits of calcium phosphate crystals in the kidneys can lead toacute kidney failurein which the kidneys stop working. Symptoms include:Fatigue and weaknessUrinating less oftenSwelling in your legs, ankles or feetFeeling like you cannot catch your breathConfusion or disorientationLightheadedness or faintingNausea and vomitingChest pain or pressureBlood in urineSeizuresComaResearch has shown that acute kidney injury that develops from TLS is a strong predictor of death.How Tumor Lysis Syndrome Is DiagnosedTumor lysis syndrome is suspected when a person undergoing chemotherapy for specific cancers like ALL, AML, or SCLC develops signs of kidney failure, metabolic acidosis, or heart rhythm problems.To aid in the diagnosis, providers often use the Cairo and Bishop classification system. This system classifies TLS based on laboratory findings and clinical features.Laboratory TLSLaboratory TLS means that two or more of the following metabolic abnormalities have occurred within three days before or seven days after the start of chemotherapy:HyperuricemiaHyperkalemiaHyperphosphatemiaHypocalcemiaThese abnormalities occur despite adequate hydration and drugs used to reduce uric acid levels in the blood.Clinical TLSClinical TLS is diagnosed when the laboratory criteria from above are met with the addition of at least one of the following scenarios:Abnormal heart rhythmsA high bloodcreatinine level(an indication of kidney failure)SeizuresHow Tumor Lysis Syndrome Is TreatedIf a person is diagnosed with tumor lysis syndrome, they will be admitted to anintensive care unit (ICU)for treatment. The treatment will consist of some or all of the following therapies:Intravenous HydrationHydration is essential to the normalization of electrolytes and the clearance of uric acid. Fluids are given intravenously (through a vein) to maintain a urine output greater than 100 milliliters per hour (mL/h).A diuretic (“water pill”) calledLasix (furosemide)may be given to help increase urine output to reach and maintain this goal.Normalizing ElectrolytesElectrolyte imbalances are monitored every four to six hours and corrected with the following measures:Hyperkalemia: Medications like Kayexalate (sodium polystyrene sulfonate), albuterol,calcium gluconate, and intravenous (IV) insulin are effective in reducing high potassium levels.Hyperphosphatemia:Drugs called oral phosphate binders—such as PhosLo (calcium acetate)—are taken with food to reduce the absorption of phosphorus in the gut.Hyperuricemia and metabolic acidosis: A drug called Elitek (rasburicase) can quickly break down uric acid so that it can be released from the body in urine.Hypocalcemia: Calcium supplements may be given if there are seizures or abnormal heart rhythms. In the absence of these symptoms, taking calcium can promote the formation of calcium phosphate crystals and increase the risk or severity of kidney failure.DialysisDialysiswould be needed if acute kidney failure occurs. There are other indications for dialysis in cases of TLS, including:Pulmonary edema(fluid in the lungs)Persistent hyperkalemiaSymptomatic hypocalcemiaHow to Prevent Tumor Lysis SyndromeIn people undergoing cancer therapy, several strategies may be implemented to prevent TLS from even occurring. These include:Closely monitoring electrolytes and kidney function with acomprehensive metabolic panelduring chemotherapyEnsuring ample hydrationMonitoring heart rhythmLimiting the dietary intake of potassium and phosphorus three days before and seven days after starting chemotherapyPreemptively administering drugs like allopurinol or rasburicase for people at risk of hyperuricemia (such as those with pre-existing kidney disease)SummaryTumor lysis syndrome is a medical emergency that occurs when a massive amount of tumor cells are killed and spill their contents into the bloodstream following chemotherapy. This can lead to a dangerous imbalance of electrolytes like potassium, phosphate, and calcium and dangerously high levels of uric acid in the blood.TLS is most common with aggressive blood cancers and certain solid tumor cancers like small cell lung cancer. The emergency treatment of TLS involves intravenous hydration, the rapid reduction of uric acid in the blood, and dialysis if kidney failure occurs.
Tumor lysis syndrome (TLS) occurs when a large amount of cancer cells die at once—either spontaneously or as the result ofcancer treatment—and release their contents into the bloodstream. This can cause a potentially fatal imbalance inelectrolyteslike potassium, calcium, and phosphate and dangerously high levels of waste products like uric acid in the blood.
TLS can cause potentially devastating symptoms like irregular heartbeats, seizures,acute kidney failure, and coma. It most often occurs with blood cancers but can happen with certain solid tumor cancers as well. The treatment is primarily focused on reducing uric acid levels and normalizing electrolyte levels with medications and hydration.
This article describes the causes and symptoms of tumor lysis syndrome, including who is most at risk. It also explains how TLS is treated and prevented.
FatCamera/E+/Getty Images
Why Does Tumor Lysis Syndrome Occur?
Tumor lysis syndrome occurs when a large number of cancer cells die suddenly. As tumor cells die (lyse) and break open, their spilled contents—including potassium, phosphate, and uric acid—are released in massive amounts into the bloodstream.
This spillage ultimately leads to the following metabolic abnormalities:
High levels of phosphate, in turn, bind to calcium to form calcium phosphate crystals, resulting in a severe drop in blood calcium levels (hypocalcemia).
The massive death of tumor cells also triggers the release of inflammatory proteins calledcytokines. This can lead to a whole-body inflammatory response known as a"cytokine storm" which can cause multi-organ failure.
Cancers Linked to TLS
Tumor lysis syndrome most often occurs with certain blood cancers and a small handful of solid tumor cancers as well. Tumors vulnerable to TLS are typically aggressive (fast-growing) and highly responsive tochemotherapy.
The cancers most commonly associated with TLS are:
TLS is less commonly associated with:
Researchers have found that more than one in four children with acute lymphoblastic leukemia will develop TLS after undergoing cancer treatment.
Other Risk Factors
Tumour lysis syndrome typically occurs at the start of chemotherapy. It can happen within a few hours of treatment but is most often seen 48 to 72 hours after chemotherapy starts.
TLS can also occur spontaneously, but this is rare.
In addition to chemotherapy, risk factors for TLS include:
What Are the Symptoms of Tumor Lysis Syndrome?
Electrolytes are electrically charged minerals that the body needs to function normally, regulating everything from heartbeats and muscle contractions to eye and brain function. Having too many or too few as a result of TLS can disrupt these functions and lead to symptoms like:
High uric acid levels can be particularly harmful, leading to a condition calledmetabolic acidosisthat can quickly become fatal if left untreated. Symptoms include:
Metabolic acidosis along with the deposits of calcium phosphate crystals in the kidneys can lead toacute kidney failurein which the kidneys stop working. Symptoms include:
Research has shown that acute kidney injury that develops from TLS is a strong predictor of death.
How Tumor Lysis Syndrome Is Diagnosed
Tumor lysis syndrome is suspected when a person undergoing chemotherapy for specific cancers like ALL, AML, or SCLC develops signs of kidney failure, metabolic acidosis, or heart rhythm problems.
To aid in the diagnosis, providers often use the Cairo and Bishop classification system. This system classifies TLS based on laboratory findings and clinical features.
Laboratory TLS
Laboratory TLS means that two or more of the following metabolic abnormalities have occurred within three days before or seven days after the start of chemotherapy:
These abnormalities occur despite adequate hydration and drugs used to reduce uric acid levels in the blood.
Clinical TLS
Clinical TLS is diagnosed when the laboratory criteria from above are met with the addition of at least one of the following scenarios:
How Tumor Lysis Syndrome Is Treated
If a person is diagnosed with tumor lysis syndrome, they will be admitted to anintensive care unit (ICU)for treatment. The treatment will consist of some or all of the following therapies:
Intravenous Hydration
Hydration is essential to the normalization of electrolytes and the clearance of uric acid. Fluids are given intravenously (through a vein) to maintain a urine output greater than 100 milliliters per hour (mL/h).
A diuretic (“water pill”) calledLasix (furosemide)may be given to help increase urine output to reach and maintain this goal.
Normalizing Electrolytes
Electrolyte imbalances are monitored every four to six hours and corrected with the following measures:
Dialysis
Dialysiswould be needed if acute kidney failure occurs. There are other indications for dialysis in cases of TLS, including:
How to Prevent Tumor Lysis Syndrome
In people undergoing cancer therapy, several strategies may be implemented to prevent TLS from even occurring. These include:
Summary
Tumor lysis syndrome is a medical emergency that occurs when a massive amount of tumor cells are killed and spill their contents into the bloodstream following chemotherapy. This can lead to a dangerous imbalance of electrolytes like potassium, phosphate, and calcium and dangerously high levels of uric acid in the blood.
TLS is most common with aggressive blood cancers and certain solid tumor cancers like small cell lung cancer. The emergency treatment of TLS involves intravenous hydration, the rapid reduction of uric acid in the blood, and dialysis if kidney failure occurs.
6 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Mirrakhumov AE, Voore P, Khan M, Ali AM.Tumor lysis syndrome: A clinical review.World J Crit Care Med. 2015;4(2):130-38. doi:10.5492/wjccm.v4.i2.130Howard SC, Jones DP, Pui CH.The tumor lysis syndrome.N Engl J Med. 2011 May 12;364(19):1844-54. doi:10.1056/NEJMra0904569Wilson FP, Berns JS.Tumor lysis syndrome: New challenges and recent advances.Adv Chronic Kidney Dis. 2014;21(1):18–26. doi:10.1053/j.ackd.2013.07.001Cairo MS, Coiffier B, Reiter A, Younes A, TLS Expert Panel.Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus.Br J Haematol. 2010;149(4):578-586. doi:10.1111/j.1365-2141.2010.08143.xLarson RA, Pui C-H. Tumor lysis syndrome: Prevention and treatment. In: UpToDate, Drews RE, Freedman AS, Poplack DG (Eds), UpToDate, Waltham, MA.Akande M, Audino AN, Tobias JD.Rasburicase-induced hemolytic anemia in an adolescent with unknown glucose-6-phosphate dehydrogenase deficiency.J Pediatr Pharmacol Ther. 2017;22(6): 471–475. doi:10.5863/1551-6776-22.6.471Additional ReadingHigdon ML, Atkinson CJ, Lawrence KV.Oncologic emergencies: Recognition and initial management.Am Fam Physician;97(11):741-78.Jones GL, Will A, Jackson GH, Webb NJ, Rule S.Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology.Br J Haematol. 2015;169(5):661-71. doi:10.1111/bjh.13403
6 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Mirrakhumov AE, Voore P, Khan M, Ali AM.Tumor lysis syndrome: A clinical review.World J Crit Care Med. 2015;4(2):130-38. doi:10.5492/wjccm.v4.i2.130Howard SC, Jones DP, Pui CH.The tumor lysis syndrome.N Engl J Med. 2011 May 12;364(19):1844-54. doi:10.1056/NEJMra0904569Wilson FP, Berns JS.Tumor lysis syndrome: New challenges and recent advances.Adv Chronic Kidney Dis. 2014;21(1):18–26. doi:10.1053/j.ackd.2013.07.001Cairo MS, Coiffier B, Reiter A, Younes A, TLS Expert Panel.Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus.Br J Haematol. 2010;149(4):578-586. doi:10.1111/j.1365-2141.2010.08143.xLarson RA, Pui C-H. Tumor lysis syndrome: Prevention and treatment. In: UpToDate, Drews RE, Freedman AS, Poplack DG (Eds), UpToDate, Waltham, MA.Akande M, Audino AN, Tobias JD.Rasburicase-induced hemolytic anemia in an adolescent with unknown glucose-6-phosphate dehydrogenase deficiency.J Pediatr Pharmacol Ther. 2017;22(6): 471–475. doi:10.5863/1551-6776-22.6.471Additional ReadingHigdon ML, Atkinson CJ, Lawrence KV.Oncologic emergencies: Recognition and initial management.Am Fam Physician;97(11):741-78.Jones GL, Will A, Jackson GH, Webb NJ, Rule S.Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology.Br J Haematol. 2015;169(5):661-71. doi:10.1111/bjh.13403
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Mirrakhumov AE, Voore P, Khan M, Ali AM.Tumor lysis syndrome: A clinical review.World J Crit Care Med. 2015;4(2):130-38. doi:10.5492/wjccm.v4.i2.130Howard SC, Jones DP, Pui CH.The tumor lysis syndrome.N Engl J Med. 2011 May 12;364(19):1844-54. doi:10.1056/NEJMra0904569Wilson FP, Berns JS.Tumor lysis syndrome: New challenges and recent advances.Adv Chronic Kidney Dis. 2014;21(1):18–26. doi:10.1053/j.ackd.2013.07.001Cairo MS, Coiffier B, Reiter A, Younes A, TLS Expert Panel.Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus.Br J Haematol. 2010;149(4):578-586. doi:10.1111/j.1365-2141.2010.08143.xLarson RA, Pui C-H. Tumor lysis syndrome: Prevention and treatment. In: UpToDate, Drews RE, Freedman AS, Poplack DG (Eds), UpToDate, Waltham, MA.Akande M, Audino AN, Tobias JD.Rasburicase-induced hemolytic anemia in an adolescent with unknown glucose-6-phosphate dehydrogenase deficiency.J Pediatr Pharmacol Ther. 2017;22(6): 471–475. doi:10.5863/1551-6776-22.6.471
Mirrakhumov AE, Voore P, Khan M, Ali AM.Tumor lysis syndrome: A clinical review.World J Crit Care Med. 2015;4(2):130-38. doi:10.5492/wjccm.v4.i2.130
Howard SC, Jones DP, Pui CH.The tumor lysis syndrome.N Engl J Med. 2011 May 12;364(19):1844-54. doi:10.1056/NEJMra0904569
Wilson FP, Berns JS.Tumor lysis syndrome: New challenges and recent advances.Adv Chronic Kidney Dis. 2014;21(1):18–26. doi:10.1053/j.ackd.2013.07.001
Cairo MS, Coiffier B, Reiter A, Younes A, TLS Expert Panel.Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus.Br J Haematol. 2010;149(4):578-586. doi:10.1111/j.1365-2141.2010.08143.x
Larson RA, Pui C-H. Tumor lysis syndrome: Prevention and treatment. In: UpToDate, Drews RE, Freedman AS, Poplack DG (Eds), UpToDate, Waltham, MA.
Akande M, Audino AN, Tobias JD.Rasburicase-induced hemolytic anemia in an adolescent with unknown glucose-6-phosphate dehydrogenase deficiency.J Pediatr Pharmacol Ther. 2017;22(6): 471–475. doi:10.5863/1551-6776-22.6.471
Higdon ML, Atkinson CJ, Lawrence KV.Oncologic emergencies: Recognition and initial management.Am Fam Physician;97(11):741-78.Jones GL, Will A, Jackson GH, Webb NJ, Rule S.Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology.Br J Haematol. 2015;169(5):661-71. doi:10.1111/bjh.13403
Higdon ML, Atkinson CJ, Lawrence KV.Oncologic emergencies: Recognition and initial management.Am Fam Physician;97(11):741-78.
Jones GL, Will A, Jackson GH, Webb NJ, Rule S.Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology.Br J Haematol. 2015;169(5):661-71. doi:10.1111/bjh.13403
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