Case Resolution

In the case of the 57-year-old man who is unresponsive, an intravenous line is established and a normal saline solution is infused. Because of his fatigue and constipation in the face of known lung cancer, a diagnosis of hypercalcemia is suspected, and serum electrolytes are drawn. His serum calcium level is measured at 15.2 mg/dL (3.8 mmol/L), and isotonic saline is started at 250 mL/hour. He is treated with intravenous furosemide and, after consultation with the oncologist on call, he is given 4 mg of zoledronic acid intravenously, as well as salmon calcitonin, 4 IU/kg intramuscularly every 12 hours. He becomes alert, and his serum calcium declines to 11.5 mg/dL 36 hours later. He is at baseline mental status 18 hours after admission.

Summary

Cancer remains the second leading cause of death in the United States. With an aging population, it is inevitable that the number of patients with acute illness and disability from malignancy will increase. The accurate diagnosis and treatment of metabolic emergencies in cancer patients can potentially forestall disability and enhance quality of life.

Pearls

The management of tumor lysis syndrome centers on establishment of hydration and control of elevated uric acid and serum potassium.

The mainstays of emergency management of hypercalcemia from malignancy are hydration and the use of furosemide and bisphosphonates.

Pitfalls

• Failure to aggressively investigate weakness and change in mental status in patients with established malignancy.
• Inadequate hydration or inadequate use of hypouricemic agents in a patient with leukemia or lymphoma who is on chemotherapy.

References

1. Body JJ. Hypercalcemia of malignancy. Semin Nephrol. 2004;24:48-54.
2. Stewart AF. Clinical practice associated with cancer. N Engl J Med. 2005;352:373-379.
3. Bilezikian JP. Drug therapy: management of acute hypercalcemia. N Engl J Med. 1992;326:1196-1203.
4. Halfdanarson TR, Hogan WJ, Moynihan TJ. Oncologic emergencies: diagnosis and treatment. Mayo Clin Proc. 2006;81(6):835-848.
5. Rizzoli R, Thiébaud D, Bundred N, et al. Serum parathyroid hormone-related protein levels and response to bisphosphonate treatment of hypercalcemia of malignancy. J Clin Endocrinol Metab. 1999;84:3545-3550.
6. Carano A, Teitelbaum SL, Konsek JD, et al. Bisphosphonates directly inhibit the bone resorption activity of isolated avian osteoclasts in vitro. J Clin Invest. 1990;85:456-461.
7. Tanvetyanon T, Stiff PJ. Management of the adverse effects associated with intravenous bisphosphonates. Ann Oncol. 2006;17:897-907.
8. Vaughn CB, Vaitkevicius VK. The effects of calcitonin in hypercalcemia in patients with malignancy. Cancer. 1974;34:1268-1271.
9. Bockman R. The effects of gallium nitrate on bone resorption. Semin Oncol. 2003;30:5-12.
10. Koo WS, Jeon DS, Ahn SJ, et al. Calcium-free hemodialysis for the management of hypercalcemia. Nephron. 1996;72:424-428.
11. Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders. 5th ed. McGraw-Hill Companies: New York, NY; 2001:707-711.
12. Ellison DH, Berl T. The syndrome of inappropriate diuresis. N Engl J Med. 2007;356:2064-2072.
13. Johnson BE, Chute JP, Rushin J, et al. A prospective study of patients with lung cancer and hyponatremia of malignancy. Am J Respir Crit Care Med. 1997;156:1669-1678.
14. Ferlito A, Rinaldo A, Devaney KO. Syndrome of inappropriate antidiuretic syndrome associated with head and neck cancers: review of the literature. Ann Otol Rhinol Laryngol. 1997;106:878-883.
15. Bressler RB, Huston DP. Water intoxication following moderate-dose intravenous cyclophosphamids. Arch Intern Med. 1985;145:548-549.
16. Anderson RJ. Hospital-associated hyponatremia. Kidney Int. 1986;29:1237-1247.
17. Markman M. Common complications and emergencies associated with cancer and its therapy. Cleve Clin J Med. 1994;12:105-114.
18. Cairo MS, Bishop M. Tumor lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127:3-11.
19. Montesinos P, Lorenzo I, Martin G, et al. Tumor lysis syndrome in patients with acute myeloid leukemia: identification of risk factors and development of a predictive model. Haematologica. 2008;93:67-74.
20. Hande KR, Garrow GC. Acute tumor lysis syndrome in patients with high-grade non-Hodgkin’s lymphoma. Am J Med. 1993;94:133-139.
21. Coiffier B, Altman A, Pui CH, et al. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008;26:2767-2778.
22. Hummel M, Reiter S, Adam K, et al. Effective treatment and prophylaxis of hyperuricemia and impaired renal function in tumor lysis syndrome with low doses of rasburicase. Eur J Haematol. 2008;80:331-336.

Contributors and Disclosures

Contributors: Dr. Jonathan M. Glauser wrote “Metabolic and Infectious Emergencies in Cancer Patients.” Dr. Glauser is vice chair of the Department of Emergency Medicine at the Cleveland Clinic Foundation and faculty member in the MetroHealth Case Western Reserve Emergency Medicine Residency Program in Cleveland, Ohio.