Tumour lysis syndrome and oncologic emergencies: Case

Framing the case

This seven-year-old boy with the Burkitt lymphoma sits at the very top of the tumour lysis risk. The large abdominal mass, the lactate dehydrogenase of three thousand, and the elevated urate together mark a high tumour burden and a high cell turnover, and the start of the chemotherapy will release a torrent of the intracellular contents. The framework that organises the case is the recognition that the tumour lysis is predictable and preventable, and the first decision is to put the prophylaxis in place before the first dose of the chemotherapy. ^[3]

The risk assessment and the prophylaxis

The boy is high risk by the Cairo stratification, because the Burkitt lymphoma has the very highest cell turnover of any childhood tumour, with a doubling time of around twenty-four hours. The prophylaxis is the foundation of the management, and it begins before the first dose. The hyperhydration with an isotonic fluid that contains no potassium is run at two to three litres per square metre per day to maintain a urine output above two millilitres per kilogram per hour. The fluid is potassium-free because the child is at risk of the hyperkalaemia. ^[1]

The rasburicase, a recombinant urate oxidase that converts the existing uric acid into the soluble allantoin, is given at zero point one five to zero point two milligrams per kilogram, and the glucose-six-phosphate-dehydrogenase status is checked first, because the rasburicase is contraindicated in the deficiency and causes a severe haemolysis and a methaemoglobinaemia. The biochemistry of the potassium, the phosphate, the calcium, the creatinine, and the urate is monitored every four to six hours for the first twenty-four to forty-eight hours, and the renal replacement therapy is kept on standby. ^[1][9]