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Journal of Clinical Oncology, Vol 22, No 16 (August 15), 2004: pp. 3430-3431 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.99.704
Is Rasburicase Needed for Prevention of Tumor Lysis Syndrome During Treatment of Less Aggressive Hematolymphoid Malignancies?Department of Oncology (MBC 64), King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia To the Editor: Rasburicase (recombinant urate oxidase) has been proven to be an effective therapy for prevention of tumor lysis syndrome and its serious consequences in patients with hematolymphoid malignancies with extremely fast proliferation kinetics such as acute leukemias with high WBC count, Burkitt's lymphoma, and lymphoblastic lymphoma with high tumor burden.1,2 Although a substantial proportion of these patients present with high lactate dehydrogenase, high uric acid, elevated creatinine, and electrolyte disturbances, 10% to 30% will develop acute renal failure requiring hemodialysis. The conclusion of the study by Coiffier et al3 about the efficacy of rasburicase in prevention of tumor lysis in a group of 100 non-Hodgkin's lymphoma patients, which included only one patient each with lymphoblastic lymphoma and Burkitt's lymphoma, might be an attempt to prevent a morbidity that does not exist at a significant scale. The largest subset of patients that was treated in his study had diffuse large B-cell lymphoma (n = 79); other patients included had anaplastic large-cell lymphoma (n = 6), peripheral T-cell lymphoma (n = 8), and transformation of indolent lymphoma (n = 5). Most of such patients are typically treated in an outpatient setting and clinically significant tumor lysis is much less frequent in these patients, even among those with higher than normal lactate dehydrogenase or uric acid. Moreover, simpler measures such as hydration and standard allopurinol administration are usually successful in preventing clinically significant tumor lysis and the rare development of acute renal failure in such patients. Only 11% of the patients in this study3 had uric acid more than 450 µmol/L and it appears that all of the patients had normal baseline creatinine. In addition, in contrast to the patients with a high grade aggressive lymphoma or leukemia, for which an immediate therapy is required because of the fast tumor kinetics, a little delay in treatment of less aggressive hematolymphoid malignancies to allow adequate hydration and oral allopurinol is unlikely to have dramatic consequences in treatment outcome. Until a well-conducted cost-effectiveness study clearly demonstrates that administration of rasburicase is appropriate for less aggressive lymphomas, we are concerned this study may pass a wrong message to the oncology physician that 3 to 7 days of parenteral administration of rasburicase is the optimal therapy for all patients with these histologies. This message comes at a time when all cancer centers worldwide are facing difficulties in securing adequate funding for the escalating cost of antineoplastic medications and other medications used for supporting management of cancer patient. The suggestion that rasburicase (a medication that at the recommended dosage may be 9,000 times more expensive than conventional allopurinol treatment4) should be used for the prevention and treatment of hyperuricemia in relatively less aggressive hematolymphoid malignancies should await additional analysis to confirm the cost effectiveness of this approach. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES 1. Goldman SC, Holcenberg JS, Finklestein JZ, et al: A randomized comparison between rasburicase and allopurinol in children with lymphoma or leukemia at high risk for tumor lysis. Blood 97:2998B–3003B, 2001
2. Pui CH, Mahmoud HH, Wiley JM, et al: Recombinant urate oxidase for the prophylaxis or treatment of hyperuricemia in patients with leukemia or lymphoma. J Clin Oncol 19:697–704, 2001
3. Coiffier B, Mounier N, Bologna S, et al: Efficacy and safety of rasburicase (recombinant urate oxidase) for the prevention and treatment of hyperuricemia during induction chemotherapy of aggressive non-Hodgkin's lymphoma: Results of the GRAAL1 (Groupe d'Etude des Lymphomes de l'Adulte Trial on Rasburicase Activity in Adult Lymphoma) Study. J Clin Oncol 21:4402–4406, 2003 4. Rasburicase (Elitek) for hyperuricemia. Med Lett Drugs Ther 44:96–97, 2002[Medline]
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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