Treatment-resistant Hypercalcemia from Ectopic PTH Hypersecretion Suspected Secondary to Disseminated Ovarian Cancer

Alexander M. Balinski^1, , Neil J. Khatter¹, Jeffrey M. Gold², Krishna S. Pothugunta², Vamshi K. Garlapaty², Steven M. Rankin², Christopher A. Thorburn³ and Jamal Abu-khaled²

¹Oakland University William Beaumont School of Medicine, Rochester, MI, 48309 USA

²Department of Nephrology, Beaumont Health, Royal Oak, MI, 48073 USA

³Department of Anatomic Pathology, Beaumont Health, Royal Oak, MI, 48073 USA

Cite this paper

Alexander M. Balinski, Neil J. Khatter, Jeffrey M. Gold, Krishna S. Pothugunta, Vamshi K. Garlapaty, Steven M. Rankin, Christopher A. Thorburn and Jamal Abu-khaled. Treatment-resistant Hypercalcemia from Ectopic PTH Hypersecretion Suspected Secondary to Disseminated Ovarian Cancer. American Journal of Medical Case Reports. 2021; 9(10):512-515. doi: 10.12691/AJMCR-9-10-9

Abstract

Hypercalcemia of malignancy (HCM) can present secondary to hypersecretion of parathyroid hormone (PTH)-related protein (PTHrP) from malignant tumors, but rare cases of HCM have also been documented due to inappropriate PTH secretion from ectopic neoplasms. Here, we report an unusual case of HCM due to hypersecretion of PTH suspected secondary to a disseminated mucinous ovarian adenocarcinoma. A 45-year-old female presented with severe hypercalcemia and significant elevations in both PTH and PTHrP two weeks after total abdominal hysterectomy with bilateral salpingo-oophorectomy and suboptimal debulking of a newly discovered left ovarian mucinous adenocarcinoma with numerous metastases. Ectopic PTH secretion was highly suspected after a negative parathyroid ultrasound. Pamidronate, calcitonin, and fluid resuscitation were unable to normalize her serum calcium, resulting in the need for dialysis and subsequent continuous renal replacement therapy. Further intervention with denosumab, etelcalcetide, and cinacalcet was attempted. Serum calcium began to decline, but repeat PTH resulted greater than 2,500 pg/mL. Unfortunately, the patient died just one week into her hospital course from septic shock and multi-organ system failure. While patients with localized PTH-secreting tumors carry a good prognosis, disseminated malignancies can result in significant morbidity and mortality due to severe treatment-resistant hypercalcemia.

Keywords

hypercalcemia, malignancy, parathyroid hormone, ovarian adenocarcinoma

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Siyam FF, Klachko DM. What is hypercalcemia? The importance of fasting samples. Cardiorenal Med. 2013; 3(4): 232-238.
[2]	Turner JJO. Hypercalcaemia - presentation and management. Clin Med (Lond). 2017; 17(3): 270-273.
[3]	Batarseh N, Al Sabie F, Evans-Molina C. SAT-494 A Very Rare Case: Hypercalcemia Caused by Ectopic PTH Secretion in Endometrial Cancer. J Endocr Soc. 2019; 3(Supplement_1).
[4]	Seccareccia D. Cancer-related hypercalcemia. Can Fam Physician. 2010; 56(3): 244-246.
[5]	Moghadam RN, Amlelshahbaz AP, Namiranian N, et al. Comparative diagnostic performance of ultrasonography and 99mTc-Sestamibi scintigraphy for parathyroid adenoma in primary hyperparathyroidism; Systematic review and meta-analysis. Asian Pac J Cancer Prev. 2017; 18(12): 3195-3200.
[6]	Goldstein RE, Billheimer D, Martin WH, Richards K. Sestamibi Scanning and Minimally Invasive Radioguided Parathyroidectomy Without Intraoperative Parathyroid Hormone Measurement. Ann Surg. 2003; 237(5): 722-731.
[7]	Auguste LJ, Attie JN, Schnaap D. Initial failure of surgical exploration in patients with primary hyperparathyroidism. Am J Surg. 1990; 160(4): 333-336.
[8]	van Heerden JA, Grant CS. Surgical treatment of primary hyperparathyroidism: An institutional perspective. World J Surg. 1991; 15(6): 688-692.
[9]	Uchida K, Tanaka Y, Ichikawa H, et al. An Excess of CYP24A1, Lack of CaSR, and a Novel lncRNA Near the PTH Gene Characterize an Ectopic PTH-Producing Tumor. J Endocr Soc. 2017; 1(6): 691-711.
[10]	Ongom PA, Odida M, Lukande RL, Jombwe J, Elobu E. Metastatic colorectal carcinoma mimicking primary ovarian carcinoma presenting as “giant” ovarian tumors in an individual with probable Lynch syndrome: A case report. J Med Case Rep. 2013; 7(1): 158.
[11]	Pickhardt PJ, Hassan C, Halligan S, Marmo R. Colorectal cancer: CT colonography and colonoscopy for detection-systematic review and meta-analysis. Radiology. 2011; 259(2): 393-405.
[12]	Nussbaum SR, Gaz RD, Arnold A. Hypercalcemia and Ectopic Secretion of Parathyroid Hormone by an Ovarian Carcinoma with Rearrangement of the Gene for Parathyroid Hormone. N Engl J Med. 1990; 323(19): 1324-1328.
[13]	Chen L, Dinh TA, Haque A. Small cell carcinoma of the ovary with hypercalcemia and ectopic parathyroid hormone production. Arch Pathol Lab Med. 2005; 129(4): 531-533.
[14]	Gabriel FGC, Picar RE. A rare case of hypercalcemic encephalopathy from ectopic secretion of parathyroid hormone. Clin Case Rep. 2020; 8(3): 423-425.
[15]	Wright JD, Tergas AI, Ananth CV, et al. Quality and Outcomes of Treatment of Hypercalcemia of Malignancy. Cancer Invest. 2015; 33(8): 331-339.
[16]	Ramos REO, Perez Mak M, Alves MFS, et al. Malignancy-Related Hypercalcemia in Advanced Solid Tumors: Survival Outcomes. J Glob Oncol. 2017; 3(6): 728-733.
[17]	Thosani S, Hu MI. Denosumab: A new agent in the management of hypercalcemia of malignancy. Futur Oncol. 2015; 11(21): 2865-2871.
[18]	Asonitis N, Kassi E, Kokkinos M, Giovanopoulos I, Petychaki F, Gogas H. Hypercalcemia of malignancy treated with cinacalcet. Endocrinol Diabetes Metab Case Rep. 2017; 2017: 17-0118.
[19]	Friedl C, Zitt E. Role of etelcalcetide in the management of secondary hyperparathyroidism in hemodialysis patients: a review on current data and place in therapy. Drug Des Devel Ther. 2018; 12: 1589-1598.