Tumor Lysis Syndrome and Venous Thromboembolic Disease: Oncology Nurse-Centric Case-Based Discussions

Dr. Brown is an assistant professor at the School of Nursing & Health Studies at Georgetown University in Washington, DC. He received his doctorate in nursing from the University of Utah in Salt Lake City. Dr. Brown’s research interests include stem cell transplant and symptom management of patients with cancer undergoing chemotherapy. He has written numerous articles on the subject in journals such as Nursing Research, Seminars in Oncology Nursing, and American Journal of Nursing. He is also the president of the Oncology Nursing Certification Corporation and an active member of the Multinational Association of Supportive Cancer Care.

Carlton G. Brown, PhD, APRN, AOCN®, reported a financial interest/relationship or affiliation in the form of: Consultant, Endo Pharmaceuticals; Speakers’ Bureau, Cytogen Corporation.

Identifying the Risk of TLS in Patients With Cancer/New Predictive Models

Tumor lysis syndrome (TLS) is a life-threatening metabolic syndrome caused by tumor breakdown, usually following cytotoxic treatment of certain types of solid or liquid malignancies. During TLS, there is a release of intracellular ions, nucleic acids, proteins, and metabolites, which can be detrimental to the human body, specifically to the kidneys. This release results in the hallmark laboratory findings of TLS which include: hyperuracemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Patients with large tumor burden and dehydration, preexisting renal impairment, or elevated pretreatment LDH levels are at high risk for TLS. Certain cancers have a higher affinity to TLS including, Burkitt’s lymphoma, lymphoblastic lymphoma, and acute leukemia. It is important to note some patients will present with TLS before the initiation of cancer treatment. TLS that goes undetected can be fatal and may result in arrhythmias, coma, renal failure, and hemorrhage. The Penn Predictive Score for TLS is a helpful tool for the identification of patients who will likely experience this syndrome. Specifically, patients of male gender with high LDH and uric acid levels are at greater risk for TLS. Strategies for prevention include the use of a predictive model, assessment of patient hydration status, and identification of medication(s) that may place the patient at higher risk for TLS. Successful interventions for TLS include hydration, medications such as allopurinol and rasburicase, and as a last resort, renal replacement therapy.

Ms. Holmes Gobel is an oncology clinical nurse specialist at Northwestern Memorial Hospital, Chicago, Illinois. She received her master’s degree from Rush University, Chicago, where she is currently an adjunct faculty member at the College of Nursing. The scope of her practice includes hematology/oncology and palliative care/hospice. She has written several publications on cancer symptom management and lectures regularly on issues related to oncology nursing. Ms. Holmes Gobel is also director at large on the Oncology Nursing Society board of directors.

Barbara Holmes Gobel, RN, MS, AOCN^®, reported a financial interest/relationship or affiliation in the form of: Speakers’ Bureau, Genentech BioOncology and sanofi-aventis U.S.

Nursing Management for the Prophylaxis Treatment of TLS

If left untreated, tumor lysis syndrome (TLS) may cause renal, neurological, and cardiac complications and even early mortality. In this presentation, case studies will illustrate how to assess patient risk level as well as how to prevent and manage TLS. The efficacy and practical considerations of therapies for the treatment of TLS will be reviewed, including intravenous fluid administration, allopurinol, and rasburicase. Additionally, the role of oncology nurses in patient education, especially regarding diet and hydration, will be addressed.

Ms. Moran is an oncology nurse practitioner in the Arthur G. James Cancer Hospital, The Ohio State University, where she works in collaboration with attending physicians to provide comprehensive care to patients with hematologic malignancies in the ambulatory setting. She received her master’s degree from the University of Pennsylvania in Philadelphia. Ms. Moran has more than 10 years of experience in the hematology/ oncology setting, and has published and lectured extensively on hematology topics, including management of treatment-related side effects.

Mollie E. Moran, MSN, CNP, reported a financial interest/relationship or affiliation in the form of: Speakers’ Bureau, Genentech BioOncology, MGI PHARMA, INC., and Novartis Pharmaceuticals Corporation.

Current Status of Treatment Options for VTE in Patients With Cancer/Acute and Long-Term Anticoagulation for VTE

Venous thromboembolism (VTE) includes deep venous thrombus (DVT) and pulmonary embolism (PE). It is a common and life-threatening complication in patients with cancer, increasing the chances of death by two- to eight-fold. Risk factors for developing VTE include older age, comorbid conditions such as obesity, infection, renal disease, and pulmonary disease. Treatment-related factors such as major surgery, hospitalization, active chemotherapy, hormonal therapy, antiangiogenic therapy, erythropoiesis-stimulating agents, and central venous catheters are additional risk factors for oncology patients. Upon diagnosis, prompt initiation of anticoagulation therapy with unfractionated heparin or low-molecular weight heparin with or without vitamin K antagonist is recommended. Prophylactic anticoagulation is suggested for inpatients with the diagnosis of active cancer who do not have contraindications to therapy with either low-molecular weight heparin or unfractionated heparin. A number of newer agents are under investigation for the treatment of VTE; management strategies vary. The oncology nurse is the primary educational resource for patients and their families. It is therefore important for nurses to have an understanding of the complex process of diagnosing, treating, and preventing VTE.