Paraneoplastic hypercalcaemia associated with TCC of bladder

Relevance of concurrent hypercalcemia in ureteric sarcoidosis complicated with bladder urothelial carcinoma: a case report

BACKGROUND

Sarcoidosis is a multisystem inflammatory disorder and can affect any organ; however, ureteric involvement is extremely rare with only four cases reported in the literature to date, all of which were diagnosed with surgical ureteral resection including a nephroureterectomy. This study reports the first case of ureteric sarcoidosis controlled with medical therapy where a differential diagnosis was performed based on the diagnostic clue of hypercalcemia. A definitive diagnosis was established without surgical resection of the ureter.

CASE PRESENTATION

A 60-year-old man presented with anorexia and weight loss. Blood tests showed renal dysfunction and hypercalcemia. Computed tomography revealed left hydronephrosis associated with left lower ureteral wall thickening, which showed high signal intensity on diffusion-weighted magnetic resonance imaging. Similarly, we detected a bladder tumor on cystoscopy, and a 2-cm-long stenosis was revealed by retrograde ureterography; therefore, ureteral cancer was suspected. Meanwhile, considering the clinical implication of hypercalcemia, a differential diagnosis of sarcoidosis was established based on elevated levels of sarcoidosis markers. Fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the left lower ureter, skin, and muscles, suggestive of ureteric sarcoidosis with systemic sarcoid nodules. For a definitive diagnosis, transurethral resection of the bladder tumor and ureteroscopic biopsy were performed. Histopathological examination revealed ureteric sarcoidosis with bladder urothelial carcinoma. Following an oral administration of prednisolone, hypercalcemia instantly resolved, the renal function immediately improved, and the left ureteral lesion showed complete resolution with no recurrence.

CONCLUSIONS

In this case, the co-occurrence of ureteral lesion with bladder tumor evoked a diagnosis of ureteral cancer. However, considering a case of ureteral lesion complicated with hypercalcemia, assessment for differential diagnosis was performed based on the calcium metabolism and sarcoidosis markers. In cases of suspected ureteric sarcoidosis from the assessment, pathological evaluation with ureteroscopic biopsy should be performed to avoid nephroureterectomy.

Soft Tissue Mineralization in Captive 2-Toed Sloths

Soft tissue mineralization was diagnosed in 19 captive 2-toed sloths ( Choloepus didactylus and Choloepus hoffmanni) ranging from 2 months to 41 years of age. Gross mineralization was evident at necropsy in 6 of 19 sloths and was prominent in the aorta and arteries. Histologically, 11 sloths had arterial mineralization, including mural osseous and chondroid metaplasia and smooth muscle hyperplasia consistent with arteriosclerosis. Visceral mineralization most commonly involved the gastric mucosa (17 sloths), kidneys (17 sloths), and lungs (8 sloths). Eleven sloths ranging in age from 5 to 41 years old had moderate to severe renal disease, which may be an important underlying cause of soft tissue mineralization in adult sloths. However, 5 sloths (juveniles and adults) had severe soft tissue mineralization with histologically normal kidneys or only mild interstitial inflammation or fibrosis, suggesting other causes of calcium and phosphorus imbalance. Degenerative cardiac disease was a common finding in 10 sloths with vascular mineralization and varied from mild to severe with fibrosis and acute noninflammatory myocardial necrosis. Although the prevalence of cardiac disease in adult sloths has not been documented, disease may be exacerbated by hypertension from degenerative arteriosclerosis as noted in this study group. Although renal disease likely contributed substantially to mineralization of tissues in most sloths in this study, nutritional causes of soft tissue mineralization—such as imbalances in dietary vitamin D or calcium and phosphorus—may be an important contributing factor.

Resolution of hypercalcemia of malignancy following radical cystectomy in a patient with paraneoplastic syndrome associated with urothelial carcinoma of the bladder

Hypercalcemia of malignancy is a common finding associated with different types of cancers; however, its association with urothelial carcinoma of the bladder is rare. We report a case of a 69-year-old male with nonmetastatic urothelial carcinoma of the bladder who developed hypercalcemia that failed to respond to medical management, but resolved completely after undergoing resection of the tumor through radical cystectomy.

A rare complication of transitional cell carcinoma of the renal pelvis: parathyroid hormone-related peptide-induced hypercalcaemia

We describe a rare occurrence of parathyroid hormone-related peptide (PTHrp) associated hypercalcaemia with a recurrence of transitional cell carcinoma of the renal pelvis. Our patient presented with serum calcium of 3.9 mmol/L, PTH of 5 ng/L and a PTHrp of 9.8 pmol/L (<2 pmol/L). He had no evidence of metastatic disease. His hypercalcaemia responded to bisphosphonate therapy. He chose to be treated conservatively and died 5 weeks after presentation. This is the seventh such case described in the literature. PTHrp-induced hypercalcaemia is associated with a grave prognosis, with a mean survival of 65 days from presentation.