Hypercalcemia of Malignancy

55 yo AAM with PMH of inoperable NSCLC on chemotherapy was admitted to the hospital with CC: Constipation for one month and blurred vision for 1 day.

He had a abnormal lab test in the outpatient chemoTx department which was the reason for the admission.

PMH:
COPD, Smoker, Lung CA with bone mets

Meds:
MS, Oxycontin, Percocet, Tylenol, Aerosols

What is the most likely lab abnormality?
HyperCa++

What do you think is the reason for the constipation?
Opiods
HyperCa++

What should we ask to check if the chemoTx is having any effect?
Fatigue?
Appetite?
Weight loss?
He was not feeling very well in general.

What are the questions on RoS that we ask in hyperCa++?
"Stones, Bones, Moans, Psychic Groans" mnemonic
Source: FP Notebook
All were negative in this patient

What do we look for on physical exam?
VS, dehydration?
He was not orthostatic or dehydrated

Lungs: decreased air entry on R


CXR-PA view; Close-up; CXR report

What tests would you order?
CBCD, CMP

Why CBCD?
Patient is having chemoTx and may have a drop in any of the 3 blood lines, e.g. leukopenia, anemia, thrombocytopenia

Labs showed severe hypercalcemia


Labs

What would you do now?
IVF and Zometa

The so called "Lasix sandwich" (1L NS - Lasix 20 - 1L NS - Lasix 20) is not recommended anymore because most of these patients are severely dehydrated.
The goal is urine output of 150 cc/hr.

What about if the patient is having CHF? Do we need a 2D Echo?
No, negative CXR and EKG have 95% predictive value in ruling out CHF.
This patient just needs fluids: NS 500 cc bolus, and then 250 cc/hr with the goal of urine output 150-200 cc/hr.

What happened?
Patient was admitted to RMF and was treated with IVF. Zometa was not immediately available (4 mg IV infusion over 4 hours, one dose), and a Pamidronate infusion was started instead (infused over 24 hrs).


Treatment

Final diagnosis:
Hypercalcemia of malignancy

What did we learn from this case?
Hypercalcemia is a known complication of lung CA.
It is an emergency and needs treatment fast.
Hydration is the most important step, Zometa is next on the list.

Also, in this particular patient, hospice care should be recommended.

References:
A Practical Approach to Hypercalcemia - AFP 2003

1 comment:

  1. Agree with hospice comment. It should be noted that for most patients hypercalemia of malignancy portends a very poor prognosis (1-2 months). The exception is for relatively 'treatable' malignancies (newly diagnosed breast cancers, hematologic malignancies early on).

    --Drew Pallimed: a palliative medicine blog

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