Simultaneous production of parathyroid hormone-related protein and granulocyte colony-stimulating factor in renal pelvic cancer

Persistent, Unexplained Leukocytosis Is a Paraneoplastic Syndrome Associated With a Poor Prognosis in Patients With Urothelial Carcinoma

BACKGROUND

We sought to define the disease characteristics and outcomes of those patients presenting with urothelial carcinoma and a persistently elevated white blood cell (WBC) count.

MATERIALS AND METHODS

We queried a prospectively maintained institutional database. Patients were included if they had had a histologic diagnosis of urothelial carcinoma and a WBC count of > 20,000 cells/μL on ≥ 2 occasions separated by 30 days. The patients' medical records were reviewed and were excluded from the analysis if an underlying cause for the leukocytosis could be identified. The clinical, histologic, and laboratory data were then collected from the remaining patient cohort.

RESULTS

We identified a total of 1410 patients with a histologic diagnosis of urothelial carcinoma, 9 (0.6%) of whom met our inclusion criteria. These 9 patients had a median age of 63 years. At their presentation with leukocytosis, all 9 had muscle-invasive disease and 5 had evidence of metastatic disease. Leukocytosis was frequently associated with hypercalcemia (n = 6), thrombocytosis (n = 5), and anemia (n = 9). Chemotherapy was able to achieve a WBC response in 3 of 5 patients, although only 1 patient demonstrated a substantial reduction in tumor volume radiographically. Extirpative surgery was able to provide a response in the laboratory parameters in 2 of 4 patients. However, all studied patients ultimately developed leukocytosis recurrence after systemic or local therapy and experienced rapid disease progression, with a median interval from leukocytosis until death of 71 days.

CONCLUSION

Paraneoplastic leukocytosis in the setting of urothelial carcinoma is a rare phenomenon but confers a poor prognosis, with a rapid progression to death.

Granulocyte colony-stimulating factor-producing upper urinary tract carcinoma: systematic review of 46 cases reported in Japan

AIMS

Granulocyte colony-stimulating factor (G-CSF)-producing upper urinary tract carcinoma is extremely rare, and we do not yet have a comprehensive understanding of the disease. This study was carried out to determine the characteristics of G-CSF-producing upper urinary tract carcinoma.

MATERIALS AND METHODS

A systematic MEDLINE and ICHUSHI WEB (Japan Medical Abstract Society) search was carried out to identify articles and conference proceedings describing patients with G-CSF-producing upper urinary tract carcinoma. The final cohort included 46 patients: eight studies were published in English, 16 in Japanese and there were 18 Japanese conference proceedings.

RESULTS

The average age of patients was 67 years and the male to female ratio was 2.5 to 1. The mean white blood cell count was as high as 33,900/μl (range 10,000-121,000) in these patients. Pretreatment serum G-CSF levels were measured in 23 patients, all of which were higher (range 55-1220 pg/ml) than normal levels. Metastasis was detected in 29 patients (63%) and lymph node and lung metastases were well observed. The most commonly reported primary treatment was surgery (33 patients), but the median survival period for these patients was short (4.5 months). Multivariate analysis showed that lymph node and/or distant metastasis (hazard ratio 2.92, P = 0.020) and the absence of adjuvant therapy (hazard ratio 3.20, P = 0.014) were independent risk factors for mortality. A total of only seven patients survived more than 1 year and most had a history of neoadjuvant/adjuvant chemotherapy and/or radiation therapy.

CONCLUSION

We believe that the presence of G-CSF-induced leukocytosis represents a distinct and highly aggressive form of upper urinary tract carcinoma. However, the results of our systematic review indicate that a multidisciplinary approach including surgery, neoadjuvant or adjuvant chemotherapy and radiotherapy may have the potential to control the disease, although we cannot provide definitive recommendations from this retrospective study.

Hypercalcemia in upper urinary tract urothelial carcinoma: a case report and literature review

Objective. We here report a patient with upper urinary tract urothelial carcinoma with hypercalcemia likely due to elevated 1,25-dihydroxyvitamin D. Methods. We present a clinical case and a summary of literature search. Results. A 57-year-old man, recently diagnosed with a left renal mass, for which a core biopsy showed renal cell carcinoma, was admitted for hypercalcemia of 11.0 mg/mL He also had five small right lung nodules with a negative bone scan. Both intact parathyroid hormone and parathyroid hormone-related peptide were appropriately low, and 1,25-dihydroxyvitamin D was elevated at 118 pg/dL. The patient's calcium was normalized after hydration, and he underwent radical nephrectomy. On the postoperative day 6, a repeat 1,25-dihydroxyvitamin D was 24 pg/mL with a calcium of 8.1 mg/dL. Pathology showed a 6 cm high-grade urothelial carcinoma with divergent differentiation. We identified a total of 27 previously reported cases with hypercalcemia and upper tract urothelial carcinoma in English. No cases have a documented elevated 1,25-dihydroxyvitamin D level. Conclusion. This clinical course suggests that hypercalcemia in this case is from the patient's tumor, which was likely producing 1,25-dihydroxyvitamin D. Considering the therapeutic implications, hypercalcemia in patients with upper urinary tract urothelial carcinoma should be evaluated with 1,25-dihydroxyvitamin D.

Hypopharyngeal squamous cell carcinoma producing both granulocyte colony-stimulating factor and parathyroid hormone-related protein

A 57-year-old woman was admitted to Hokkaido University Hospital because of dysphagia. Laryngoscopy indicated hypopharyngeal tumor histologically diagnosed as squamous cell carcinoma (SCC). A combination of radiotherapy and chemotherapy was performed for 2 months, and the hypopharyngeal lesion completely regressed. After 4 months, fever, anorexia, and malaise appeared, and chest X-ray and CT indicated two large tumors in the right lung. Transbroncheal lung biopsy (TBLB) specimens were diagnosed as SCC. Laboratory data showed high levels of serum granulocyte colony-stimulating factor (G-CSF) and parathyroid hormone-related protein (PTHrP). Subsequently, positron emission tomography (PET) showed multiple metastases to several organs including the liver, spine, skull, and thigh. Two months after readmission, the patient died with no success of chemotherapy. At autopsy, the lung tumor was clearly positive for both G-CSF and PTHrP on immunohistostaining. Retrospectively, examination showed that the primary pharyngeal tumor was focally positive for these two cytokines. Thus, a certain population of hypopharyngeal cancer producing G-CSF and PTHrP, spread to various organs and contributed to the rapid progression and poor prognosis. This case is presented with a discussion of several other cases in the literature.

Laryngeal squamous cell carcinoma with ectopic production of granulocyte colony-stimulating factor and parathyroid hormone-related protein

It is known that malignant tumors occasionally produce hormone-like substances. However, they rarely produce two or more kinds of hormonal factors simultaneously. We describe the clinical, biochemical, and immunohistochemical findings in a patient with squamous cell carcinoma of the larynx associated with leukocytosis and hypercalcemia, without bone metastasis. The serum granulocyte colony-stimulating factor (G-CSF) level was 222 pg/ml (normal, < 38 pg/ml), and decreased to 15 pg/ml after surgery. The serum parathyroid hormone-related protein (PTHrP) level was 5.6 pmol/l (normal, < 0.5 pmol/l), and this also decreased, to less than 0.5 pmol/l. G-CSF and PTHrP increased again with tumor recurrence. The production of G-CSF from the tumor was confirmed by immunohistochemical staining with monoclonal antibody against human recombinant G-CSF. The tumor was revealed to produce both G-CSF and PTHrP. In this article, we describe this very rare case of primary squamous cell carcinoma of the head and neck with the simultaneous ectopic production of more than one hormone-like substance.

Regulation of granulocyte colony-stimulating factor and parathyroid hormone-related protein production in lung carcinoma cell line OKa-C-1

Previously we have established a clonal squamous cell carcinoma cell line OKa-C-1 derived from lung cancer of a patient with marked leukocytosis and hypercalcemia. OKa-C-1 cells simultaneously produce granulocyte colony-stimulating factor (G-CSF) and parathyroid hormone-related protein (PTHrP) at the single cell level and cause paraneoplastic syndromes in nude mice bearing the tumor. It is known that the production of G-CSF and PTHrP is individually regulated by inflammatory cytokines in various malignant cells. To investigate the common factors in the regulation of G-CSF and PTHrP production in OKa-C-1 cells, we examined the effects of some inflammatory agents [lipopolysaccharide (LPS), phorbol-12-myristate-13-acetate (PMA), tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1) beta and IL-6] on G-CSF and PTHrP production, by means of enzyme-linked immunosorbent assay (ELISA), immunoradiometric assay (IRMA) and quantitative reverse transcription-polymerase chain reaction (RT-PCR). TNF-alpha or IL-1beta induced both G-CSF and PTHrP production in the conditioned medium. TNF-alpha synergized with IL-1beta to significantly increase G-CSF production. In addition, TNF-alpha and IL-1beta strongly induced G-CSF mRNA with peaks at 2 and 6 h respectively. Although PTHrP production was also strongly induced by TNF-a PTHrP mRNA expression was more strongly induced by PMA than by TNF-alpha. Thus, TNF-alpha and IL-1beta could be common factors that individually and synergistically regulate G-CSF and PTHrP production in OKa-C-1 cells. Moreover, G-CSF and PTHrP production could be not only transcriptionally, but also posttranscriptionally regulated by other factors.