Tumor Lysis Syndrome

Clinical manifestations

• Large tumor burden or a rapidly proliferating tumor -» spontaneous or chemotherapy-

induced release of intracellular electrolytes and nucleic acids

• Most common w Rx of high-grade lymphomas (Burkitt's) and leukemias (ALL,

AML, CML in blast crisis): rare with solid tumors; rarely due to spontaneous necrosis

• Electrolyte abnormalities: t K. t uric acid, t PO4 - I Ca

• Renal failure (urate nephropathy)

Prophylaxis

• Allopurinol 300 mg qd to bid PO or 200-400 mg mJ IV (adjusted for renal fxn) &

aggressive hydration prior to beginning chemotherapy or XRT

• Rasburicase (recombinant urate oxidase) 0.15 mg kg or 6 mg fixed dose (except in obese

Pts) & aggressive hydration prior to beginning chemotherapy or XRT (see below) Treatment

• Avoid IV contrast and NSAIDs

• Allopurinol • IV hydration ♦ diuretics to T UOP

• Alkalinization of urine w isotonic NaHCOi f UA solubility & 1 risk of urate nephropathy

• Rasburicase (recombinant urate oxidase. 0.15-0.2 mg kg d x 3-7 d) for severe hyperuricemia, especially in aggressive malignancy; uric acid levels must be drawn on ice to quench ex vivo enzyme activity uC0 2<X>3:21.4402;AaaHocmoto/2006:l15:35)

• Treat hyperkalemia, hyperphosphatemia, and symptomatic hypocalcemia

• Hemodialysis may be necessary; early renal consultation for Pts w renal insuffic. or ARF

CANCER OF UNKNOWN PRIMARY SITE

Evaluation of Cancer of Unknown Primary

Path

Possible Sources

Markers

Imaging

Additional Path

Colon, Upper Gl, Pane.

CEA.CA19-9

Endoscopy EUS

CDX1.CK7 20

0

HCC

AFP

Abd Pelvic CT

01 T5

Breast

CA-15-3

Mammography

ER PR.GCDFP

<

Ovarian. Prostate

CA125.PSA

Pelvic U S

CA-12S. PSAP

Lung

Chest CT

TTF1.CK7

i

Lung

None

Chest CT

TTF1.CK7

Head & Neck

Laryngoscopy

a-

Esophageal

Endoscopy

M

Cervix. Anus

Germ cell

hCG.AFP

Testicular U S

PLAP. isochrom 12p

>. C

Lymphoma

LDH

PET

LC A flow, cytogenetics

1 I

Thyroid

Thyroglob.

Thyroid U S

Thyroglobulin

Iii

GIST, Sarcoma

Abd Pelvic CT

c-KIT, desmin, vimentin

a

Neuroendocrine

NSE. chromogranin

Consider EM for all

Additional studies for each possible source listed in same row. May also need tests for adeno squam for poorfy-M.

Additional studies for each possible source listed in same row. May also need tests for adeno squam for poorfy-M.

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