癌症病人的高钙血症及其诊断处理

Hypercalemia of malignancy
Humoral hypercalcemia of malignancy(HHM)
– parathyroid hormone-related peptide(PTHrP) binds to
PTH receptor – non-small cell lung cancer,cancer of breast cancer , kidney ,head and neck ,and bladder
Discussion
Hypercalcemia
Clinical maifestations:
– Renal manifestation: polyuria , nephrolithiasis – GI symptoms: anorexia , nausea , vomiting ,
and constipation – Neurologic finding :weakness , fatigue ,confusion ,stupor and coma – EKG manifestation : shortened QT interval
pain ,syncope – Common:Lung , pancreatic , GI,breast , ovarian , GU cancers , lymphomas , and brain tumors. – General anesthesia:20%-30% risk of DVT
Trousseau' Trousseau's syndrome
Local osteolytic hypercalcemia(LOH)
– local production of hormones or cytokines spread to
the bone or bone marrow and increase bone resorption – breast cancer , myelmoa , lymphoma , leukemia
Physical examination
General appearance: weakness(+) Cons: clear, E4V5M6 Vital sign: TPR: 37.6/100/20 BP: 124/81mmHg HEENT: Conj: injected Sclera: anicteric Neck: supple, no LAP, no JVE Thyroid: N.P. Axillary: no LAP Chest: symmetric expansion breathing sound: R't coarse Heart: RHB without murmur, tachycardia Abd: soft and flat, no tenderness , no rebounding pain Hypoactive bowel sound, Liver/spleen: impalpable, no palpable mass Ext: freely movable, no pitting edema
Trousseau' Trousseau's syndrome
Treatment
– Intravenous heparin – Proximal DVT and relative contraindication to
heparin(brain metastases or pericardial effusion):placement of a filter in the IVC to prevent PE – Coumadin: 3 to 6 months – Major surgical procedure:heparin prophylaxis or pneumatic boots
I.ParathyoidI.Parathyoid-related A.primary hyperparathyroidism 1.solitary adenomas 2.multiple endocrine neoplasia B.lithium therapy C.familial hypocalcuric hypercalcemia II.MalignancyII.Malignancy-related A.solid tumor with metastases(breast) B.solid tumor with humoral mediation of hypercalcemia(lung,kidney) C.hematologic malignancies(multiple myeloma,lymphoma,leukemia) III.Vitamin D-related DA.vitamin d intoxication B.1,25 (OH)2D;sarcoidosis and other granulomatous diseases C.idiopathic hypercalcemia of infancy IV.Associated with high bone turnover A.hyperthyroidism B.immobilization C.thiazides D.vitamin a intoxication V.Associated with renal failure A.severe secondary hyperparathyroidism B.aluminum intoxication k-alkali syndrome
以下讨论的是一个癌症病人化疗 之后的相关症状,不能仅仅用化 疗药物的副作用来敷衍了事,草 草处理病人化疗之后的不适,本 例中的病人,其原因为高钙血症, 本幻灯片提出了高钙血症的相关 鉴别诊断和处理
Present illness
This 65 y/o male patient was diagnosed lung cancer stage IV with bone meta S/P post C/T.He had received 3-3 course chemotherapy with Gemzar with Cisplatin 28 days cycle . He was referred to our hospital and had received chemotherapy with Taxotere 28 days cycling since 90-0523. He felt nausea and general malaise during this course of chemotherapy. Weakness, fever, chillness for days & fall down yesterday. Bil. hand & L't knee abrasion w'd was note. This time, he is admitted for another course chemotherapy.
Definition
– The coexistence of peripheral venous
thrombosis with visceral carcinoma is called Trousseau's syndrome.
Pathogenesis
– bedrest or immobilized – procoagulants or cytokines from tumor cells or
associated inflamatory cells
Trousseau' Trousseau's syndrome
Clinical Manifestations:
– DVT: swelling or pain in leg – Pulmonary embolism: dyspnea ,chest
Differential Diagnosis of Hypercalcemia Criterion Clinical issues alone >90% caused by hyperparathyhyperparathyriodism or cancer If asymptomatic or chronic Levels of PTH measured by PTH assay Increased or normal(despite hypercalcemia) Decreased or undetectable Conclusion
Laboratory
WBC:17000 n-seg76.2% eosin 0% Hb:10.0 Plt:420K lymph 16.2% mono 7.4% baso 0.2%
GOT:52 GPT 67 BUN:20.3 Cr :0.7 Na:127 K:4.1 Ca: 8.6
Impression
1.pneumonia,RLL 2.lung cancer with bone metastasis , stage IV s/p CT 3.suspected SIADH
Hosptial course
8/31 urine culture : Cadida albicans 9/6 left leg edema+++,R/O DVT 9/8 sputum cluture:E coli 9/9 Fragmin 1/2 amp x 3 days +lasix 1# qd 9/12 dopper moderate DVT over left lower limb 9/21 Ca:12.7 Lasix+ 5% GS 1000 ml 9/24 Aredia 4mp 9/25 Aredia 4 amp 9/27 Ca:10.2
Diagnosis
– DVT: impedance plethysmography.confirmed
Hale Waihona Puke by venography /Doppler ultrasound – Pulmonary embolism:CXR,EKG,ABG,ventilation perfusion scan.sometimes pulmonary angiogram
Treatment
ECF volume restoration Saline diuresis Pamidronate Calcitonin Plicamycin Glucosteroid Oral phosphate Dialysis
Trousseau' Trousseau's syndrome
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Past history denied DM,HTN Personal history 1. Smoking(+), 2PPD/day for 40+ years 2. Alcohol drinking(+) 3. Medication: denied 4. Allergy history: denied
Hyperparathyroidism
Hyperparathyroidsim confirmed Acute presentation with or without symptom – screen carefully for malignancy Chronic –malignancy unlikely,sarunlikely,sarcoidosis or other cause