Two Cases of Humoral Hypercalcemia of Malignancy in Metastatic Cholangiocarcinoma
A 68-year-old male patient presented with weight loss of 6 kg over two months and abdominal pain for one week. He had no past medical history. Ultrasonography performed at the local hospital showed a mass lesion in the liver, and he was referred to our hospital. An abdominopelvic CT scan showed CC with innumerable liver to liver metastases and node metastases. Sono-guided liver biopsy was performed and the pathologic diagnosis was adenocarcinoma, either primary or metastatic. Because no primary mass was found by esophagogastroduodenoscopy and colonoscopy, we made a diagnosis of CC with liver metastasis and began treatment with palliative chemotherapy, gemcitabine plus cisplatin. His tumor was stable until 28 June 2011, when he visited the outpatient clinic for the eighth cycle of gemcitabine and cisplatin approximately six months after his initial diagnosis.\nAt that time, his blood test was remarkable for a corrected serum calcium level of 11.8 mg/dL. Otherwise, there were no symptoms or signs related to hypercalcemia and he was in good performance status. After receiving treatment with intravenous hydration and pamidronate, he received the 8th cycle of chemotherapy as scheduled. We scheduled an appointment for another visit to recheck his condition as well as his serum calcium level. When he returned to the outpatient clinic one week later, his mental status was somewhat somnolent. A blood test showed an aggravated corrected serum calcium level of 14.1 mg/dL and decreased liver function; aspartate aminotransferase was three times the normal level (102 IU/mL; normal range, 13 to 34 IU/mL), alkaline phosphatase was 340 U/L (normal range, 38 to 115 U/L), and albumin was decreased to 2.8 mg/dL (normal range, 3.3 to 5.3 mg/dL). Other blood tests were not remarkable. CT scan revealed aggravation of the main mass and a metastatic lesion in the liver, and newly developed ascites. CEA and CA 19-9 levels were elevated to 981.32 ng/mL and 7,450 U/mL, respectively. As the PTH level was suppressed to 4.8 pg/mL and PTH-rP level was increased to 8.3 pmol/L, we were able to make a diagnosis of HHM. He was hospitalized and treated with intravenous hydration and pamidronate. After admission, his hypercalcemia was corrected to a certain degree, but never returned to normal range. Despite improvement in his mental status, his performance status did not recover from Eastern Cooperative Oncology Group 3. Hence we discontinued chemotherapy and treated him with the best supportive care until he expired on 24 July 2011, only approximately one month after diagnosis of HHM.