What cancers are associated with acute tumor lysis syndrome (ATLS)?

Cancers Most Commonly Associated with Acute Tumor Lysis Syndrome

Acute tumor lysis syndrome (ATLS) most frequently occurs in hematologic malignancies with high proliferative rates and high tumor sensitivity to chemotherapy, particularly Burkitt's lymphoma and B-cell acute lymphoblastic leukemia (B-ALL). 1

High-Risk Hematologic Malignancies

• Burkitt's lymphoma - Highest risk, with TLS rates of 8.4% in pediatric patients 1
• B-cell acute lymphoblastic leukemia (B-ALL) - Particularly high risk with TLS rates of 26.4% 1
• Other aggressive non-Hodgkin lymphomas 1
• T-cell acute lymphoblastic leukemia (T-ALL) 1
• Acute myeloid leukemia (AML) - 17% incidence of TLS (12% laboratory TLS, 5% clinical TLS) 1

Intermediate-Risk Hematologic Malignancies

• Other B-cell non-Hodgkin lymphomas 1
• Chronic lymphocytic leukemia (CLL) - Particularly when treated with fludarabine (0.33% incidence) 1

High-Risk Solid Tumors

Although less common than in hematologic malignancies, TLS can occur in certain solid tumors:

• Bulky small cell lung cancer 1
• Metastatic germ cell carcinoma (gonadal or extragonadal) 1
• Medulloblastoma with metastases 2

Risk Factors That Increase TLS Probability

Tumor-Related Factors:

• High tumor burden reflected by:
  • Elevated serum LDH levels 1
  • WBC count >50,000/mm³ 1
  • Extensive bone marrow involvement 1
  • Large tumor size 1
  • Bulky disease with liver metastases 1

Patient-Related Factors:

• Elevated pre-treatment serum uric acid level 1
• Pre-existing renal damage 1
• Tumor infiltration in the kidney 1
• Obstructive uropathy 1
• Advanced age 1
• Dehydration 1
• Hyponatremia 1

Treatment-Related Factors:

• Highly active, cycle-specific cytotoxic drugs (cytosine arabinoside, etoposide, cisplatin) 1
• Corticosteroid therapy 1
• Monoclonal antibodies (rituximab, gemtuzumab ozogamicin, campath) 1
• Other agents: hydroxyurea, fludarabine, imatinib, bortezomib 1
• Radiotherapy 1

Clinical Implications and Mortality Risk

The mortality rate associated with TLS is significantly higher in solid tumors (approximately 35%) compared to hematologic malignancies 1. This disparity likely results from:

1. Earlier initiation of prophylactic measures in hematologic patients
2. Closer monitoring during and after chemotherapy in hematologic patients
3. Delayed recognition of TLS risk in solid tumor patients

Prevention and Management Approach

For patients with high-risk malignancies:

• Aggressive IV hydration (maintain urine output ≥100 mL/hour in adults) 3
• Rasburicase administration (0.20 mg/kg/day IV) for rapid uric acid degradation 3
• Close monitoring of electrolytes, renal function, and uric acid levels every 6-12 hours 3

Important Clinical Pitfalls

1. Underestimating TLS risk in solid tumors: Despite being less common, TLS in solid tumors carries a higher mortality rate 1
2. Delayed recognition: Spontaneous TLS can occur even before chemotherapy initiation 1
3. Inadequate monitoring: High-risk patients require frequent laboratory monitoring (every 6-12 hours initially) 3
4. Calcium management errors: Avoid calcium replacement in asymptomatic hypocalcemia as it may increase calcium phosphate precipitation 3
5. Urine alkalinization: This is no longer recommended when using rasburicase as it provides no additional benefit and may increase calcium phosphate precipitation 3

In pediatric patients, the risk is particularly high, with up to 70% of children with malignancies developing TLS 1, necessitating aggressive prophylactic measures in this population.