eMedicine Specialties > Pediatrics: General Medicine > Oncology

Tumor Lysis Syndrome: Differential Diagnoses & Workup

Author: Alan K Ikeda, MD, Assistant Professor, Department of Pediatrics, Division of Hematology and Oncology, David Geffen School of Medicine at UCLA; Assistant Director of Pediatric Blood and Marrow Transplantation, Mattel Children's Hospital
Coauthor(s): Kathleen Sakamoto, MD, Professor, Department of Pediatrics, Division of Hematology-Oncology and Pathology and Laboratory Medicine, Mattel Children's Hospital, David Geffen School of Medicine, University of California at Los Angeles; Koyamangalath Krishnan, MD, FRCP, FACP, Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine and Chief of Hematology-Oncology, Program Director, Hematology-Oncology Fellowship, James H Quillen College of Medicine at East Tennessee State University; Amit P Sarnaik, MD, Staff Physician, Department of Pediatrics, Wayne State University and Children's Hospital of Michigan
Contributor Information and Disclosures

Updated: Sep 26, 2008

Differential Diagnoses

Other Problems to Be Considered

Patients with cancer are at increased risk of renal failure from etiologies other than tumor lysis syndrome (TLS). Prerenal causes include volume depletion from anorexia, vomiting, diarrhea, and bleeding. Pelvic or retroperitoneal masses can lead to kidney failure from postrenal urinary tract obstruction. Renal parenchymal diseases include tumor infiltration, myeloma kidney, drug nephrotoxicity from chemotherapeutic agents or antibiotics, radiocontrast nephropathy, vasculitis, and cryoglobulinemic glomerulonephritis. The combination of volume depletion, hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia strongly support the diagnosis of tumor lysis syndrome as opposed to other causes.

Workup

Laboratory Studies

In patients with tumor lysis syndrome (TLS), a sample of blood obtained by a wide-bore needle or, preferably, an indwelling cannula should be used to obtain a biochemical profile of the patient for biochemical monitoring, which includes serum sodium, potassium, chloride, and bicarbonate.

  • Blood chemistry
    • Most patients have laboratory derangements in lactate dehydrogenase (LDH), potassium, phosphate, calcium, uric acid, and abnormal renal functions 1-3 days following the initiation of chemotherapy.
    • Hyperkalemia is often the first life-threatening abnormality.
    • High-risk patients should have laboratory monitoring (BUN, creatinine, phosphate, uric acid, LDH, and calcium levels) prior to therapy and for 48-72 hours after treatment induction. Follow measurements at least twice daily or more often if evidence of tumor lysis syndrome develops.
  • Urine pH
    • Urine alkalinization prevents renal precipitation of uric acid, but may increase the risks for nephrocalcinosis.
    • If alkaline diuresis is used, regular determinations of urine pH levels should guide the extent of therapy.

Imaging Studies

  • Radiography of the chest is useful to determine the presence of a large tumor (eg, mediastinal mass).
  • Perform ultrasonography or CT scanning of the abdomen and retroperitoneum immediately if mass lesions in the abdomen or renal failure are present. Intravenous contrast may be contraindicated in a patient with renal insufficiency.

Other Tests

  • Because increased urine flow rates help to inhibit crystal deposition in renal tubules, close monitoring of urine output is necessary to assess adequacy of hydration. Monitoring urine output for signs of oliguric renal failure is also necessary.
  • Frequent cardiac assessment (ECG or continuous cardiac monitoring) is necessary to monitor electrocardiographic changes, which may herald a lethal arrhythmia caused by potassium and calcium disturbances.

Histologic Findings

  • Pathologic studies demonstrate deposits of uric acid within the distal renal tubule lumina, causing intrarenal hydronephrosis.
  • Uric acid crystals can also be seen within tubular epithelial cells and the medullary microcirculation.
  • Uric acid precipitates may also occur in the renal pelvis and ureters, leading to hydronephrosis and acute renal failure (ARF) from extrarenal sources.

More on Tumor Lysis Syndrome

Overview: Tumor Lysis Syndrome
Differential Diagnoses & Workup: Tumor Lysis Syndrome
Treatment & Medication: Tumor Lysis Syndrome
Follow-up: Tumor Lysis Syndrome
References
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References

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Further Reading

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Keywords

tumor lysis syndrome, TLS, acute tumor lysis syndrome, ATLS, hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, acute renal failure, ARF, Burkitt lymphoma, T-cell acute lymphoblastic leukemia, hepatoblastoma, neuroblastoma, obstructive uropathy, pericarditis, uremia, renal colic, arthralgia, arthritis, hypertension

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Contributor Information and Disclosures

Author

Alan K Ikeda, MD, Assistant Professor, Department of Pediatrics, Division of Hematology and Oncology, David Geffen School of Medicine at UCLA; Assistant Director of Pediatric Blood and Marrow Transplantation, Mattel Children's Hospital
Alan K Ikeda, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Blood and Marrow Transplantation, and American Society of Pediatric Hematology/Oncology
Disclosure: emedicine Honoraria author

Coauthor(s)

Kathleen Sakamoto, MD, Professor, Department of Pediatrics, Division of Hematology-Oncology and Pathology and Laboratory Medicine, Mattel Children's Hospital, David Geffen School of Medicine, University of California at Los Angeles
Kathleen Sakamoto, MD is a member of the following medical societies: American Society of Hematology, American Society of Pediatric Hematology/Oncology, New York Academy of Sciences, Society for Pediatric Research, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

Koyamangalath Krishnan, MD, FRCP, FACP, Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine and Chief of Hematology-Oncology, Program Director, Hematology-Oncology Fellowship, James H Quillen College of Medicine at East Tennessee State University
Koyamangalath Krishnan, MD, FRCP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society of Hematology, and Royal College of Physicians
Disclosure: Nothing to disclose.

Amit P Sarnaik, MD, Staff Physician, Department of Pediatrics, Wayne State University and Children's Hospital of Michigan
Amit P Sarnaik, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Stephan A Grupp, MD, PhD, Director, Stem Cell Biology Program, Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania
Stephan A Grupp, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Hematology, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Steven K Bergstrom, MD, Assistant to the Chairman, Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland
Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology
Disclosure: Nothing to disclose.

CME Editor

Helen SL Chan, MBBS, FRCP(C), FAAP, Senior Scientist, Research Institute; Professor, Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Canada
Helen SL Chan, MBBS, FRCP(C), FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Society of Hematology, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA, Executive Director, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC; Professor of Medicine, Oncology, and Pediatrics, Georgetown University
Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American Association for Cancer Research, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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