Tumor+Lysis+Syndrome

=**Tumor Lysis Syndrome (TLS)** =

Tumor lysis syndrome (TLS) is the most common disease-related emergency encountered by physicians caring for children or adults with hematologic cancers.

Pathophysiology
TLS is a metabolic disturbance caused by rapid destruction of cancer cells or following the initiation of cytotoxic therapy and the release of their toxic contents into the blood stream. Cancer cells may die as part of their cell cycle even without treatment, such as in a highly proliferative cancer like leukemia, or, typically, after treatment with chemotherapeutic drugs. As the cancer cells die, they release large amounts of intracellular potassium, phosphate and purine nucleotides. In fact, dying cancer cells start releasing potassium even before they lyse. There is more potassium, phosphorus, nucleic acids, and cytokines than the body’s homeostatic mechanisms can deal with. The kidneys are primarily involved in excreting urate, xanthine (metabolic by-product of nucleic acid), and phosphate, which can precipitate and form cystals in any part of the renal system. The accumulation of toxic products and uric acid crystals, as well as other drug, physical, and physiological insults to the kidney (see figure below) can lead to acute renal failure (ARF) before the clinical signs of TLS become evident.



TLS can result in life-threatening hemodynamic and renal complications if it is not managed correctly. Despite several advances in supportive care and monitoring, TLS still poses considerable danger to many patients with cancer. Most of the severe complications of TLS can be prevented through measures, such as hydration, alkalinization, and use of the uric acid-lowering agents allopurinol and rasburicase. //**Nursing assessment and management is essential in preventing and treating TLS.**//

=Characteristics that put a patient at risk for TLS are: =
 * 1) Tumor with a high proliferative rate (rapid division and growth); tumor with a high sensitivity to chemotherapy; and tumor of large size, i.e. “bulky disease”.
 * 2) Decreased kidney function and elevated lactate dehydrogenase (LDH) at baseline also increases risk.
 * 3) Most often, TLS is associated with the administration of induction chemotherapy, but it has been reported to occur with radiation therapy, corticosteroids, hormonal agents, biologics, monoclonal antibodies, intrathecal chemotherapy and chemo-embolization.
 * 4) TLS may even occur spontaneously, before the initiation of therapy.

**Signs & Symptoms**
Signs and symptoms of TLS may be evident within a few hours after the start of chemotherapy but more often within 24 to 48 hours. The release of large amounts of potassium that the kidneys cannot completely excrete, leads to hyperkalemia, which can result in cardiac arrhythmias. Likewise, kidney dysfunction results in hyperphosphatemia, hyperuricemia, and hypocalcemia, which lead to several manifestations:



=Diagnosis Criteria = A commonly accepted definition of TLS includes a **laboratory** component and a **clinical** component.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">"Laboratory" TLS includes two or more of the following:
<span style="font-family: Arial,Helvetica,sans-serif;">* Serum Uric acid greater than or equal to 8 mg/dl –OR- a 25% increase from baseline
 * <span style="background-color: initial; font-family: Arial,Helvetica,sans-serif;">Serum **//Potassium//** greater than or equal to 6 mEq/dl –OR- a 25% increase from baseline
 * <span style="background-color: initial; font-family: Arial,Helvetica,sans-serif;">Serum **//Phosphorous//** greater than or equal to 6.5 mg/dl –OR- a 25% increase from baseline
 * <span style="background-color: initial; font-family: Arial,Helvetica,sans-serif;">Serum //**Calcium**// less than or equal to 7 mg/dl –OR- a 25% decrease from baseline

<span style="font-family: Arial,Helvetica,sans-serif;">**"Clinical" TLS includes laboratory TLS plus one of the following:**
 * <span style="background-color: initial; font-family: Arial,Helvetica,sans-serif;">Serum //**creatinine**// greater than or equal to 1.5 times the upper limit
 * <span style="background-color: initial; font-family: Arial,Helvetica,sans-serif;">Cardiac arrhythmias or sudden cardiac death
 * <span style="background-color: initial; font-family: Arial,Helvetica,sans-serif;">Seizures

=<span style="font-family: Arial,Helvetica,sans-serif;">**Radiology** = <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Radiologic procedures to assess TLS risk typically include a chest x-ray and renal ultrasound. Use of IV contrast material should be avoided in these procedures because of the additional stress it places on the kidneys to excrete the “heavy” contrast substance. Chest and abdominal computed tomography (CT) scans are also frequently used to assess tumor size and location, in addition to assessing risk for TLS. Pay special attention to the abdomen in radiologic scans because renal dysfunction may be caused by the lymphoma pressing on the renal artery limiting blood flow to the kidneys or the kidney itself. In this case, the patient would need intervention to correct these prior to the start of therapy. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">(Secola, 2006)

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Prophylactic prevention & management of TLS

 * 1) <span style="font-family: Arial,Helvetica,sans-serif;">Start central venous access and place on an oncology or intensive care unit
 * 2) <span style="font-family: Arial,Helvetica,sans-serif;">Obtain baseline electrocardiogram
 * 3) <span style="font-family: Arial,Helvetica,sans-serif;">Ensure rigorous hydration - approximately 3 L/m2/day to maintain urine output of at least 100 mL/m2/day. If necessary, diuretics such as furosemide and/or mannitol may be used to maintain urine output.
 * 4) <span style="font-family: Arial,Helvetica,sans-serif;">Obtain baseline lab values including: LDH, uric acid, sodium, potassium, creatinine, BUN, phosphorus, and calcium. Check these values q6-8 hr for the first 48 to 72 hr after therapy, and then tapered according to risk.
 * 5) <span style="font-family: Arial,Helvetica,sans-serif;">Administer allopurinol 200 - 300 mg/m2/day or rasburicase 0.20 mg/kg/day, IV over 30 min for 3 to 7 days.
 * 6) <span style="font-family: Arial,Helvetica,sans-serif;">(Optional) Alkalinization of urine with sodium bicarbonate in IV fluids.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 130%;">**Medications**
__<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**//Allopurinol//** __ <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Allopurinol has been used for some time now to help prevent TLS. It blocks uric acid production by inhibiting xanthine oxidase, and it is effective in preventing further development or buildup of uric acid. Allopurinol is predominantly administered orally. It is also available in an IV formulation. For young children, the tablets must be crushed up and administered 3 times a day, but it is easily given. Because allopurinol does not typically produce an immediate response, it may not provide enough renal protection for high-risk patients. It also does not affect the uric acid that has already formed, which is a concern in patients with an elevated level of uric acid. Allopurinol administration can also result in hypoxanthine and xanthine accumulation.

__<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**//Rasburicase//** __ <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Rasburicase is a newer uric acid-lowering agent, and it is currently the only pharmacologic alternative to allopurinol. It is a recombinant urate-oxidase enzyme derived from the Aspergillus flavus gene, and it works by oxidizing uric acid into the water-soluble substance allantoin, which the kidney excretes easily. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Nurses administering rasburicase should be aware that its rapid action can degrade uric acid in blood samples at room temperature, resulting in an artificially low level of uric acid. Therefore, when obtaining tumor lysis laboratory values, blood samples should be collected in prechilled heparin tubes, immediately placed in ice, and should be analyzed within 4 hours of collection.

=<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">Nursing Interventions = <span style="font-family: Arial,Helvetica,sans-serif;">Nursing interventions should include monitoring of urine output and alkalinization, when sodium bicarbonate is used. Any decrease in output should be reported; diuretics should be given and/or IV fluids should be adjusted accordingly.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;"> Hydration is the first and most important line of prevention. IV fluid should be 3000 mL/m2/24 hours or more (amount may vary depending on age and comorbidities) and <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;"> continued for several days to maintain a urine output of more than 100 cc/m2/hour and a urine specific gravity of less than 1.010. It is especially important to work with <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;"> physicians and residents to ensure that the patient receives no additional potassium during hydration, even if the patient’s potassium level is normal because the patient will <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;"> be exposed to an elevated level of potassium when lysis begins.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">1. Observe for fluid overload - Monitor weight, output, vital signs and respiratory status. **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;"> Tumor lysis laboratory values should be obtained every 6 to 12 hours minimum, especially during the first few days of treatment. The nurse also should continuously monitor <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;"> cardiac, respiratory, neuromuscular, and gastrointestinal function, in addition to checking for edema and weight changes.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">2. Monitor laboratory values and avoid using nephrotoxic medications (aminoglycoside antibiotics, NSAIDs). **


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">3. It may be necessary to institute a RENAL DIET, which is low in potassium and phosphorus. (Contact Dietitian) **


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Limiting fluids
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Eating a low-protein diet (this may be recommended)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Restricting salt, potassium, phosphorous, and other electrolytes
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Getting enough calories if weight loss is present.

**The Renal Diet**
The following information was obtained from [|DaVita]

<span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Patients sometimes have problems remembering which foods contain potassium and which ones have phosphorus, partly because some foods are high in both potassium and phosphorus. These are the "double jeopardy" foods that are best to avoid or use in very small amounts. <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">For some of the double jeopardy foods (on the left), there are alternatives (on the right) that will help keep potassium and phosphorus under control. **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Double Jeopardy Foods (High Potassium & ** || **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Alternatives ** **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Alternatives ** || <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12pt; vertical-align: baseline;">**An extra caution about phosphorus** <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Foods, such as deli meats and colas, which have phosphates added in processing, are especially high in phosphorus. Phosphates are often used as a preservative or as an ingredient in processed foods. For that reason, encourage patients to read food labels carefully and look for words that mean phosphorus in the ingredient section such as the ones below: <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">These ingredients used as preservatives may be more easily absorbed than phosphorus from natural food sources. That is why it’s important to avoid foods with these ingredients.
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Most high potassium foods come from plants. Fruits and vegetables tend to be the high potassium sources.
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">High phosphorus foods are mainly from animals. High-protein foods, such as meats, along with dried beans and peas tend to be high in phosphorus.
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Double jeopardy foods that are high in both potassium and phosphorus include dairy foods, nuts, seeds, chocolate and whole grain foods.
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">High potassium ** || **<span style="font-family: Arial,sans-serif; font-size: 9pt;">High phosphorus ** || **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Double jeopardy —High in potassium & phosphorus ** ||
 * * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Fruits
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Vegetables || * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Meat
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Poultry
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Fish and seafood
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Wild game
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Eggs
 * <span style="background-color: transparent; font-family: Arial,sans-serif; font-size: 9pt;">Dried beans and peas || * <span style="background-color: transparent; font-family: Arial,sans-serif; font-size: 9pt;">Milk
 * <span style="background-color: #fefef9; font-family: Arial,sans-serif; font-size: 9pt;">Dairy products
 * <span style="background-color: #fefef9; font-family: Arial,sans-serif; font-size: 9pt;">Nuts and seeds
 * <span style="background-color: #fefef9; font-family: Arial,sans-serif; font-size: 9pt;">Chocolate
 * <span style="background-color: #fefef9; font-family: Arial,sans-serif; font-size: 9pt;">Whole grain products ||
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Double Jeopardy Foods (High Potassium & High Phosphorus) **
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Cheese || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Vegan rella cheese, low-fat cottage cheese, sprinkle of parmesan cheese (use very small amounts of extra sharp cheeses for the maximum flavor) ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Chocolate || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Desserts made with lemon or apple, white cake, rice-crispy treats ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Cream Soup || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Broth-based soups made with pureed vegetables or make soups with Mocha Mix® nondairy creamer or Rich’s Coffee Rich® ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Dried beans and peas || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Green beans, wax beans ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Ice Cream || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Mocha Mix® frozen dessert, sorbet, sherbet, popsicles ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Milk || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Mocha Mix® nondairy creamer, Coffeemate®, Rich’s Coffee Rich®, Rice Dream® original, unenriched rice beverage ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Nuts || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Low-salt snack foods including pretzels,tortilla chips, popcorn, crackers, Sun Chips® ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Peanut butter || <span style="font-family: Arial,sans-serif; font-size: 9pt; vertical-align: baseline;">Low-fat cream cheese, jam or fruit spread ||
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Phosphoric acid
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Dicalcium phosphate
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Monocalcium phosphate
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Pyrophosphates
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Hexametaphosphate
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Polyphosphates
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Sodium phosphate

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 12pt;">Other foods the patient may be instructed to **__limit or avoid__** are sweets and salty foods such as the following:
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Candy (candy bars, hard candy, chocolate, jelly beans, gum drops)
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Regular sugar
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Syrup (maple, chocolate)
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Honey
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Molasses
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Pies, cakes, cookies, donuts
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Ice cream
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Canned foods
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">BBQ sauce, ketchup
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Onion, garlic or table salt
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">TV dinners
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Meat tenderizer
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Marinades
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Nuts
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Pizza
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Salted chips and snacks
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Soy Sauce
 * <span style="font-family: Arial,sans-serif; font-size: 9pt;">Worcestershire sauce

**The following can be consumed by someone on a renal diet:**
<span style="font-family: Arial,sans-serif; font-size: 12pt;">Carbohydrate foods <span style="font-family: Arial,sans-serif; font-size: 9pt;">*Portions of dairy products are often limited to 4 ounces due to high protein, potassium or phosphorus content || <span style="font-family: Arial,sans-serif; font-size: 9pt;">Note: Fruit canned in unsweetened juice is usually recommended. || <span style="font-family: Arial,sans-serif; font-size: 12pt;">Higher protein foods <span style="font-family: Arial,sans-serif; font-size: 12pt;">Higher fat foods <span style="font-family: Arial,sans-serif; font-size: 12pt;">Beverages
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Milk and nondairy ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">skim or fat-free milk, non-dairy creamer, plain yogurt, sugar-free yogurt, sugar-free pudding, sugar-free ice cream, sugar-free nondairy frozen desserts*
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Breads and starches ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">white bread, unsweetened, refined dry cereals, cream of wheat, grits, malt-o-meal, noodles, pasta, rice, bagel (small), hamburger bun, unsalted crackers, cornbread (made from scratch), flour tortilla ||
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Fruits and juices ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">apples, apple juice, applesauce, apricot halves, berries including: strawberries, raspberries, cranberries, blackberries and blueberries, low sugar cranberry juice, cherries, fruit cocktail, grapefruit, grapes, grape juice, kumquats, mandarin oranges, pears, pineapple, plums, tangerine, watermelon
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Starchy vegetables ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">corn, peas, mixed vegetables with corn and peas (eat these less often because they are high in phosphorus), potatoes (soaked to reduce potassium, if needed) ||
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Nonstarchy vegetables ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">asparagus, beets, broccoli, Brussel sprouts, carrots, cabbage, cauliflower, celery, cucumber, eggplant, frozen broccoli cuts, green beans, iceberg lettuce, kale, leeks, mustard greens, okra, onions, red and green peppers, radishes, raw spinach (1/2 cup), snow peas, summer squash, turnips ||
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Meats, cheeses and eggs ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">lean cuts of meat, poultry, fish and seafood; eggs, low cholesterol egg substitute; cottage cheese (limited due to high sodium content) ||
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Seasoning and calories ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">soft or tub margarine low in trans fats, mayonnaise, sour cream, cream cheese, low fat mayonnaise, low fat sour cream, low fat cream cheese ||
 * **<span style="font-family: Arial,sans-serif; font-size: 9pt;">Beverages ** || <span style="font-family: Arial,sans-serif; font-size: 9pt;">water, Crystal Light®, diet clear sodas (Diet Sprite®, diet gingerale), homemade tea or lemonade sweetened with an artificial sweetener ||

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 1.1em;">__**For Renal friendly recipes please visit:**__
<span style="font-family: Arial,Helvetica,sans-serif;">

=<span style="font-family: Arial,Helvetica,sans-serif;">Teaching for Patients and Family Members = <span style="font-family: Arial,Helvetica,sans-serif;">Education for the patient and family should include symptoms to be reported, a discussion of the patient's typical diet, and what foods should be avoided (those high in potassium & phosphorus; bananas, oranges, tomatoes, milk products, prepared/processed foods, sodas, chocolate and nuts). The patient should be encouraged to maintain adequate fluid intake and be aware of the need for accurate input and output monitoring. This can be a very scary time for patients, and thus the support of a knowledgeable nurse can make all the difference.

<span style="font-family: Arial,Helvetica,sans-serif;">Journal articles
<span style="font-family: Arial,Helvetica,sans-serif;">Howard, S.C., Jones, D.P., and Pui, C. The Tumor Lysis Syndrome, 2011, //The New England Journal of Medicine,// 364(19), 1844-1854 <span style="font-family: Arial,Helvetica,sans-serif;"> <span style="font-family: Arial,Helvetica,sans-serif;">Held-Warmkessel, J. How to Prevent and Manage Tumor Lysis Syndrome, 2010, //Nursing2010,// 26-31 <span style="font-family: Arial,Helvetica,sans-serif;"> <span style="font-family: Arial,Helvetica,sans-serif;">Secola, R., Tumor Lysis Syndrome: Nursing Management and New Therapeutic Options, 2006, //Proceedings of the Johns Hopkins Advanced Studies in Nursing,// 4(3), 41-48 <span style="font-family: Arial,Helvetica,sans-serif;"> <span style="font-family: Arial,Helvetica,sans-serif;">Arrambide, K, and Toto, R.D., Tumor Lysis Syndrome, 1993, //Seminars in Nephrology,// 13(3), 273-280 <span style="font-family: Arial,Helvetica,sans-serif;">

<span style="font-family: Arial,Helvetica,sans-serif;">Website references & resources
<span style="font-family: Arial,Helvetica,sans-serif;">[|OncoLink - Abramson Cancer Center of the University of Pennsylvania] <span style="font-family: Arial,Helvetica,sans-serif;">**Allopurinol info:** [] <span style="font-family: Arial,Helvetica,sans-serif;">**Rasburicase info:** []