Oncologic Metabolic Emergencies

Gastrointestinal stromal tumour-induced hypercalcaemia

Hypercalcaemia is recognised as the most common oncological metabolic emergency, with several proposed underlying mechanisms. Nevertheless, hypercalcaemia has been rarely reported as a complication in patients with gastrointestinal stromal tumours (GISTs). GISTs are uncommon mesenchymal tumours of the gastrointestinal tract. There are only nine previous cases of hypercalcaemia occurring in patients with GIST reported in the literature. We report a case of a man in his 70s with a background of metastatic GIST on fourth-line treatment. The patient presented with new hypercalcaemia and acute kidney injury. Despite medical management, his calcium remained elevated and he deteriorated secondary to significant disease progression.

Tumor Lysis Syndrome

BACKGROUND

Tumor lysis syndrome is a life-threatening oncologic emergency in adult and pediatric patients with hematologic cancer. It occurs most often in malignancies with rapid cell turnover and large tumor burden, but its incidence has risen in solid tumors. The subsequent release of tumor cell contents into the bloodstream results in dangerous electrolyte and metabolic disturbances.

OBJECTIVE

To provide acute and critical care nurses with a comprehensive review targeted to critical care nursing practice. Recognition of hallmark signs and symptoms will improve early detection and intervention.

METHODS

A literature review was performed using the following keywords: tumor lysis syndrome, diagnosis, nursing, early detection, and early diagnosis in PubMed and tumor lysis syndrome, diagnosis, early diagnosis, and early detection in CINAHL. Included studies were published in 2014 or later.

RESULTS

Tumor lysis syndrome causes hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia. These laboratory disturbances can lead to potentially destructive complications including renal injury, arrhythmias, seizures, and neuromuscular instability.

DISCUSSION

Acute and critical care nurses can use disease-related risk factors and clinical presentations associated with these laboratory derangements to determine the level of monitoring and intervention necessary for impacted patients.

CONCLUSIONS

Knowledge of risk factors and clinical presentations will enhance the ability of nurses in clinical practice to prevent adverse events and complications that result from tumor lysis syndrome.

Multiple osteolytic primary peripheral T-cell bone lymphoma: the first case report

Peripheral T-cell lymphoma accounts for about 10% of all cases of non-Hodgkin’s lymphoma. However, less than 5% of patients with non-Hodgkin’s lymphoma present with hypercalcaemia as the initial symptom, and less than 1% present with primary bone lesions. We herein describe a 76-year-old Chinese man who was diagnosed with primary bone adult T-cell lymphoma with extensive osteolysis, including bone loss in the radius, as the initial manifestation. He had developed severe generalised bone pain and an inability to raise his arms. X-ray examination revealed osteolytic destruction of the forearm with loss of the radial diaphysis. The patient was diagnosed with peripheral T-cell lymphoma based on his immunohistochemical results. He began treatment with the CHOPE chemotherapy regimen, which resulted in significant improvement of his bone pain.

Calcitriol-Mediated Hypercalcemia, Somatostatin Receptors Expression and 25-Hydroxyvitamin D3-1α- Hydroxylase in GIST Tumors

Hypercalcemia is a common complication in cancer patients Mainly caused by Parathyroid hormone-related protein (PTHrP) secretion and metastasis. Calcitriol secretion is a rare source of hypercalcemia in solid tumors, especially in gastrointestinal stromal tumors (GIST). We present a case report of a female patient with a 23 cm gastric GIST that expressed somatostatin-receptors and presented with severe hypercalcemia due to calcitriol secretion. Calcium control was achieved with medical treatment before the use of targeted-directed therapies. Surgery was performed and allowed complete tumor resection. Two years later, patient remains free of disease. Molecular analysis revealed the mRNA expression of 25-hydroxyvitamin D₃-1-hydroxylase (1αOHase) and vitamin-D receptors in the tumor cells, confirming the calcitriol-mediated mechanism. Furthermore, the expression of the endotoxin recognition factors CD14 and TLR4 suggests an inflammatory mediated mechanism. Finally, the expression of somatostatin-receptors, especially SST2 might have been related with clinical evolution and prognosis in this patient.

The Cancer Emergency Department-The Ohio State University James Cancer Center Experience

In 2015, The James Cancer Hospital's Emergency Department (ED) opened at The Ohio State University Wexner Medical Center's ED. Careful planning was undertaken to assure that the needs of patients with cancer would be addressed. Strong relationships between experts in hematology, oncology, and emergency medicine were built to maximize the positive impact. Ongoing reevaluation of operational needs facilitates optimal patient flow, resource use, and opportunities to build and develop new resources. The results are evident in improved patient satisfaction in the cancer ED and a much smoother flow of patients into the system.

The Oncologic Emergency Medicine Fellowship

The United States cancer population is growing and is projected to grow further. The current cancer population has a high rate of emergency department admission. Further training about oncologic emergencies may be needed and would ideally strive to care for the whole patient, including sequelae of the malignancy, progressive disease, symptom control, adverse effects of treatment, and palliative care. The James Cancer Hospital at The Ohio State University Wexner Medical Center and The University of Texas MD Anderson Cancer Center fellowship training programs in oncologic emergency medicine are described.

Gastrointestinal Stromal Tumor Induced Hypercalcemia

Hypercalcemia in patients with cancer is a common laboratory finding affecting up to 44% of that patient population. 1,25-Dihydroxyvitamin D₃ mediated hypercalcemia is one of the rare mechanisms of this endocrine emergency in cancer patients. It is even rarer for solid organ neoplasms to present with hypercalcemia mediated through the production of 1,25-dihydroxyvitamin D₃. We report a case of a 77-year-old female who presented to the hospital with hypercalcemia and later was found to have metastatic gastrointestinal stromal tumor. There have been only 5 cases of gastrointestinal stromal tumor described in literature resulting in hypercalcemia. In our case, the mechanism of hypercalcemia was thought to be related to overproduction of 1,25-dihydroxyvitamin by tumor cells. The patient had a favorable response to imatinib with normalization of serum calcium level. Unfortunately, she developed fluid retention due to imatinib which was discontinued resulting in relapse of hypercalcemia that was resistant to all other treatment options.

Emergencies in Hematology and Oncology

The development of medical emergencies related to the underlying disease or as a result of complications of therapy are common in patients with hematologic or solid tumors. These oncological emergencies can occur as an initial presentation or in a patient with an established diagnosis and are encountered in all medical care settings, ranging from primary care to the emergency department and various subspecialty environments. Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. This article reviews the most common oncological emergencies and provides practical guidance for initial management of these patients.

Hypercalcemia in metastatic GIST caused by systemic elevated calcitriol: a case report and review of the literature

Background

Hypercalcemia is the most common oncologic metabolic emergency but very rarely observed in patients with gastrointestinal stromal tumour, which is a rare mesenchymal malignancy of the gastrointestinal tract. We describe a case of hypercalcemia caused by elevated levels of activated vitamin D in a patient with gastrointestinal tumour. Prior to this case report, only one paper has reported an association between hypercalcemia, gastrointestinal stromal tumours and elevated levels of vitamin D.

Case presentation

An otherwise healthy 70-year-old Caucasian woman, previously treated for duodenal gastrointestinal stromal tumour, was diagnosed with liver metastasis, and relapse of gastrointestinal stromal tumour was confirmed by biopsy. At presentation, the patient suffered from severe symptoms of hypercalcemia. The most common causes of hypercalcemia, hyperparathyrodism, parathyroid hormone-related peptide secretion from tumour cells, and metastatic bone disease, were all dismissed as the etiology. Analysis of vitamin D subtypes revealed normal levels of both 25-OH Vitamin D2 and 25-OH Vitamin D3, whereas the level of activated vitamin D, 1,25 OH Vitamin D3, also referred to as calcitriol, was elevated.

Conclusion

The fact that plasma calcitriol decreased after initiation of oncological treatment and the finding that hypercalcemia did not recur during treatment support the conclusion that elevated calcitriol was a consequence of the gastrointestinal stromal tumour. We suggest that gastrointestinal stromal tumours should be added to the list of causes of humoral hypercalcemia in malignancy, and propose that gastrointestinal stromal tumour tissue may have high activity of the specific enzyme 1α-hydroxylase, which can lead to increased levels of calcitriol and secondarily hypercalcemia.