Tumor Lysis Syndrome Management in Community Oncology Settings

Background

Tumor lysis syndrome (TLS) can complicate the management of patients with bulky chemosensitive cancers. TLS incidence and severity are increasing with new highly effective agents for hematologic cancers. However, prophylaxis and management vary widely, even within the same center.

Methods

We examined TLS management and outcomes from records of 14383 newly-diagnosed adults with lymphoma treated from 2010- 2019 at 110 member hospitals of the Guardian Research Network (GRN, www.GuardianResearch.org), a non-profit community oncology consortium with a database containing patients' entire medical, including all demographics, diagnoses, labs, medications, procedures, encounters, and notes of all kinds (clinical, radiology reports). Anonymized, de-identified data about demographics, diagnosis, treatment, supportive care, and outcomes was analyzed to determine patterns of TLS management in the community setting. Natural language processing was used to identify clinicians' references to tumor lysis syndrome, risk assessment, and cancer bulk.

Results

Of 529784 cancer patients in the Guardian Research Network database, there were 14383 newly-diagnosed adults with lymphoma, of whom 81% received no uric acid lowering therapy, 17% received allopurinol or febuxostat, and only 2% received Rasburicase. TLS management varied by region: 11% of patients in Virginia received uric acid lowering therapy vs 26% in South Carolina (p<0.001) and lymphoma subtype: 11% Hodgkin lymphoma, 26% B-cell non-Hodgkin lymphomas, p<0.001). Acute kidney injury (AKI) occurred in 4.3% of patients and logistic regression confirmed NHL (versus Hodgkin), black race (versus white), and older age as risk factors (p<0.01 for each). 216 patients (1.5%) died within 30 days. Of special note, bone marrow infiltration in acute leukemia patients was not noted as a site of bulky disease, despite the fact that a marrow with 50% infiltration of leukemic cells typically contains 700 grams of cancer, and represents bulky disease that places the patient at significant risk for TLS if treated with highly active agents.

Conclusions

Early acute kidney injury is common in patients with B-cell lymphomas. Assessment of TLS risk and prophylaxis is warranted, especially when using new, highly effective chemotherapy agents in patients with bulky disease. Assessment of tumor bulk was rarely documented in the medical records.

Table

View largeDownload slide

Table

View largeDownload slide

Close modal