Hypercalcemia

1
Morning Report 4/5/2000
Victor Ghobrial, MD
Thomas McGlynn, MD
2
HPI

• 61 yrs old WM who has not seen his PCP for the
  past 10 yrs.
• C/O weakness for 2 m with loss of weight 20 lbs..
• He retired from his job as a plumber 3 m back and
  was doing a private job when he felt too weak to
  perform and only then he realized he was
  deteriorating.

3
Past Med Hx

• Pneumonia 10 years ago
• No CAD
• No HTN
• No DM
• NO CA

4
Meds

• ASA
• Tums lots of
• NKDA

5
Social Hx

• Retired Plumber who worke din heating systems an
  din cleaning out soot.
• Heavy smoker 1 p/day for gt 30 yrs
• Heavy alcohol drinker in the past

6
ROS

• Loss of weight 20lbs over 2 m in spite of good
  appetite.
• No fever, night sweats cough or SOB.
• No dysuria or frequency.
• No abdominal pain, diarrhea or constipation.
• No skin rash or other symptoms.

7
Physical Exam

• 61 male asthenic physique
• Vitals WNL
• HEENT unremarkable
• Neck supple, no JVD or carotid bruits
• Ht RRR S1 S2 audible
• Lungs CTAs B/L
• Abd Soft, no organomegally
• Ext No E,C,C ve PP
• Neuro Awake and alert but disoriented X3. No
  neuro deficits

8
Labs

• Hgb Hct WBCs Plat
  
  11.0 32 6.5
  243
• Cr BUN Na K Cl CO2
  3.2
  33 134 3.1 94 30
• Ca 15.8 Phos 2.6
• CK CKMB CKI TroponinI
  493 9.1
  1.8 0.4

9
What do you think?

• Confused
• Lost 20 lbs over 2 m
• Hypercalcemic
• Renal insufficiency
• Physical exam WNL

10
Hypercalcemia
Hyperparathyroidism
Malignancy
Metabolic Dis.
11
Hyperparathyroidism

• It is the most common cause in ambulatory
  patients, accounting for gt90 percent of cases.
• Parathyroid hormone causes
  - increased bone resorption
  - GI
  absorption
  - renal absorption

12
(No Transcript)
13
Our patient.

• PTH 5.9
• Calcium 13.2
• Makes you think..?

14
Malignancy

• Among hospitalized patients, cancer is the most
  common cause, accounting for about 65 percent of
  cases, and hyperparathyroidism accounts for
  another 25 percent.
• Increased bone resorbtion osteoclast activity
• PTH-related substance secreted by tumors
• Direct erosion by tumor cells

15
Hypercalcemia in Malignancy
Common in these neoplasms

• Solid tumor
• breast
• lung
• pancreas
• kidneys
• ovary

• Hematolgic
• myeloma
• lymphosarcoma

16
Multiple Myeloma

• Serum protein electrophoresis -ve
• Urine protein electrophoresis -ve
• Bone Marrow Bx -ve

17
Hypercalcemia Rx

• IVFNSS Lasix ( renal secretion)
• Pamidronate ( osteoclast activity)
• Calcitonin ( bone calcification)

18
Hospital Course.....

• Pt responded to therapy.
• Hypercalcimia resolved.
• Renal failure improved.
• Pt regained baseline mental functioning.

19
Now what next ?...

• Work up for an occult malignancy
• Lung CT of chest was -ve
• GI CEA 2.0, Colonoscopy -ve,
  EGD peptic ulcer Rx
  PPI
• Blood work up for MM -ve
• Prostate PSA 18.3

20
ANY CHANGE IN YOUR THOUGHTS?
21
Prostate Bx

• Moderate to poorly differentiated adenocarcinoma
  of prostate, Gleason 8.
• Prostate carcinoma involves 70 of the prostate
  tissue.

22
Prostate Cancer
23
Carcinoma of the prostate

• Detected either clinically or at autopsy as a
  microscopic, pathologically well-differentiated
  tumor of little clinical importance.
• Estimates are that 179,300 men will be diagnosed
  with prostate cancer in 1999 and that 37,000
  deaths will occur.
• Prostate cancer is the most common cancer in men
  in the United States except for non-melanoma skin
  cancer.

24
Increase in incidence

• The reasons are not known.
• The incidence of microscopic cancer is similar in
  Japanese and white men in the United States, but
  the incidence of clinically evident disease is
  much higher in American men.
• Japanese men who migrate to the mainland United
  States develop prostate cancer at a similar rate
  as white men.
• Findings suggest that both genetic and
  environmental factors are operative in the
  conversion of microscopic into evident prostate
  cancer.

25
CLINICAL PRESENTATION

• The manner in which the disease is diagnosed
  today is different from that of 10 years ago.
• In the past prostate cancer was first detected by
  digital rectal examination or because the patient
  had urinary symptoms.
• In the 1990s, prostate cancer is often diagnosed
  after a man has been found to have an elevated
  screening serum PSA concentration.

26
Symptomatic presentation

• Symptoms are usually related to urinary tract
  obstruction caused by prostatic enlargement
  (urgency, nocturia, frequency, and hesitancy)
• Because benign prostatic hyperplasia is so
  common, prostate cancer may exist in men who also
  have benign prostatic hyperplasia (BPH).

27
Asymptomatic presentation

• Prostate cancer that is asymptomatic can be
  detected as a firm nodule on a routine digital
  rectal examination or, with increasing frequency,
  by an elevated serum PSA concentration.

28
PSA concentration

• Malignant tissue generates more PSA than normal
  or hyperplastic tissue.
• Cancerous tissue may disrupt the prostate-blood
  barrier, further increasing the serum
  concentration of PSA.
• A serum PSA concentration gt4.0 ng/mL is
  considered abnormal in most assays.

29
PSA concentration

• A serum PSA of 4.1 to 10.0 ng/mL increases the
  likelihood of finding intracapsular and
  extracapsular tumors by 1.4 to 3.0 and 3.2 to
  5.1-fold, respectively.
• A serum PSA greater than 10.0 ng/mL increases the
  likelihood of finding intracapsular and
  extracapsular tumors by 0.4 to 3.0 and 23 to
  50-fold, respectively.

30
Prostatic biopsy

• Mandatory if the serum PSA concentration is
  greater than 10 ng/mL, even in the presence of a
  normal rectal examination and ultrasonography.
• Increasing numbers of men are undergoing biopsy
  for any elevation of serum PSA.

31
DIAGNOSTIC STUDIES

• The positive predictive value of digital rectal
  examination for identifying prostate cancer
  varies from 15 to 30 percent .
• The positive predictive value of serum PSA
  testing is similarly low, ranging from 17 to 28
  percent .
• Transrectal ultrasonography also has a relatively
  low positive predictive value. The primary use of
  this procedure is to guide prostate biopsy.

32
Prostate Biopsy

• The gold standard for prostate cancer diagnosis.
  
• Obtain a specimen with a biopsy gun in any
  suspicious areas.
• Complications include only mild rectal spotting,
  hematospermia, or hematuria rarely, patients
  experience more significant rectal bleeding or
  sepsis.

33
Tumor Histology (Gleason scale)

• Tumors are graded from one to five based upon the
  degree of glandular differentiation and
  structural architecture.
• Grade one represents the most well-differentiated
  appearance and grade five represents the most
  poorly differentiated.
• A primary score and a secondary score is then
  given.
• The prognosis is directly related to the pattern
  score.

34
Thank You