Criteria

Risk stratification for TLS[35][41]​​

Patients can be categorized as low, intermediate, or high risk depending on the type of malignancy, treatment sensitivity (of the tumor), disease stage, white blood cell (WBC) count, tumor burden (bulk), lactate dehydrogenase (LDH) levels, and pre-existing renal impairment/renal abnormality.

Low-risk patients include those with:

  • Solid tumors, except rare solid tumors that are chemosensitive (e.g., neuroblastoma, germ cell tumors, small cell lung cancer), or others with bulky or advanced disease

  • Chronic myeloid leukemia: chronic phase

  • Chronic lymphocytic leukemia when treated exclusively with alkylating agents

  • Multiple myeloma

  • Hodgkin lymphoma

  • Acute myeloid leukemia with WBC count <25,000/microliter and LDH <2 times the upper limit of normal (ULN)

  • Indolent/low proliferating non-Hodgkin lymphoma (e.g., small lymphocytic lymphoma, follicular lymphoma, marginal B-cell lymphoma, MALT lymphoma, mantle cell lymphoma [non-blastoid], cutaneous T-cell lymphoma, and anaplastic large cell lymphoma [adults])

Patients with low-risk disease who have renal dysfunction/involvement should be categorized as intermediate risk.[35]

Intermediate-risk patients include those with:

  • Rare solid tumors that are chemosensitive (e.g., neuroblastoma, germ cell tumors, small cell lung cancer), or others with bulky or advanced-stage disease

  • Early-stage Burkitt lymphoma with LDH <2 times the ULN

  • Early-stage lymphoblastic lymphoma with LDH <2 times ULN

  • Acute lymphoblastic leukemia with WBC count <100,000/microliter and LDH <2 times ULN

  • Acute myeloid leukemia with WBC count ≥25,000/microliter to <100,000/microliter, or WBC count <25,000/microliter and LDH ≥2 times ULN

  • Chronic lymphocytic leukemia with WBC count ≥50,000/microliter and/or treated with fludarabine or targeted agents (e.g., rituximab, lenalidomide, obinutuzumab, venetoclax)

Patients with intermediate-risk disease who have renal dysfunction/involvement, or uric acid, potassium, and/or phosphate levels above the normal range, should be categorized as high risk.[35]

High-risk patients include those with:

  • Certain high-grade non-Hodgkin lymphoma (e.g., advanced-stage Burkitt lymphoma or lymphoblastic lymphoma) and bulky high-grade non-Hodgkin lymphoma (e.g., diffuse large B-cell lymphoma)

  • Acute lymphoblastic leukemia with WBC count ≥100,000/microliter, or WBC count <100,000/microliter and LDH ≥2 times ULN

  • Acute myeloid leukemia with WBC count ≥100,000/microliter

  • Chronic lymphocytic leukemia treated with venetoclax if there is a high tumor burden (lymph node ≥10 cm or lymph node ≥5 cm and absolute lymphocyte count [ALC] ≥25,000/microliter) or a medium tumor burden (lymph node 5 cm to <10 cm; or ALC ≥25,000/microliter) in those with creatinine clearance <80 mL/min

Cairo and Bishop grading classification for TLS (2004)[2]

Grade 0

  • No laboratory TLS; creatinine ≤1.5 times ULN; no clinical manifestations.

Grade 1

  • Laboratory TLS; creatinine 1.5 times ULN; cardiac arrhythmia but medical intervention is not indicated; no seizure activity.

Grade 2

  • Laboratory TLS; creatinine >1.5 to 3.0 times ULN; cardiac arrhythmia requiring nonurgent medical intervention; one brief generalized seizure, or seizures well controlled by anticonvulsants, or infrequent focal motor seizures not interfering with activities of daily living.

Grade 3

  • Laboratory TLS; creatinine >3 to 6 times ULN, cardiac arrhythmias symptomatic and incompletely controlled medically or requiring a device (e.g., defibrillator); seizure activity with altered consciousness or poorly controlled seizure disorder with breakthrough generalized seizures.

Grade 4

  • Laboratory TLS; creatinine >6 times ULN; life-threatening arrhythmia associated with heart failure, hypotension, syncope, or shock; seizure activity that is prolonged, repetitive, or difficult to control.

Grade 5

  • Laboratory TLS and death.

Use of this content is subject to our disclaimer