High risk of tumor lysis syndrome at first cycle: bulky disease (≥10 cm nodal mass OR spl...

Deterministic view of the source YAML entity. Clinical authority remains with the cited source IDs and reviewer sign-off state.

ID	`RF-UNIVERSAL-TLS-RISK`
Type	Red flag
Status	reviewed 2026-04-25 \| pending_clinical_signoff
Diseases	None declared
Sources	`SRC-ESMO-MZL-2024` `SRC-NCCN-BCELL-2025`

Red Flag Origin

Definition	High risk of tumor lysis syndrome at first cycle: bulky disease (≥10 cm nodal mass OR splenomegaly ≥15 cm) OR LDH ≥2× ULN OR leukemic phase (ALC ≥25 k/µL with circulating tumor cells) OR rapidly proliferative histology (Burkitt, HGBL, lymphoblastic, AML, ALL).
Clinical direction	intensify
Category	oncologic-emergency

Trigger Logic

{
  "any_of": [
    {
      "comparator": ">=",
      "finding": "dominant_nodal_mass_cm",
      "threshold": 10
    },
    {
      "comparator": ">=",
      "finding": "splenomegaly_cm",
      "threshold": 15
    },
    {
      "comparator": ">=",
      "finding": "ldh_ratio_to_uln",
      "threshold": 2.0
    },
    {
      "comparator": ">=",
      "finding": "absolute_lymphocyte_count_k_ul",
      "threshold": 25
    },
    {
      "finding": "leukemic_phase",
      "value": true
    },
    {
      "finding": "tls_high_risk_histology",
      "value": true
    }
  ],
  "type": "composite_score"
}

Notes

Howard et al. 2011 NEJM TLS-risk stratification. NCCN Burkitt v2.2025 §BURK-A mandates rasburicase for high-risk; allopurinol for intermediate. ESMO guidance on intensive lymphoma regimens (DA-EPOCH-R, R-CHOP cycle 1) recommends 24-48h pre-cycle hydration + allopurinol when LDH ≥2× ULN. Engine should surface this RF in the plan's supportive-care section alongside the chosen regimen, not as an indication-switch.

Used By

Red flag

RF-BURKITT-EMERGENCY-TLS - Burkitt lymphoma with active or imminent tumor lysis syndrome at diagnosis: LDH >2× ULN,...
RF-ONCOLOGIC-EMERGENCY-TLS - Tumor lysis syndrome (TLS), Cairo-Bishop laboratory or clinical criteria. Laboratory TLS:...