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Abstract: FR-PO669

Curious Case of Hypercalcemia

Session Information

Category: Trainee Case Report

  • 1500 Onco-Nephrology

Authors

  • Ramaswamy, Kavitha, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
  • Katz-Greenberg, Goni, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
  • Yadav, Anju, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
Introduction

Hypercalcemia is a well-known phenomenon in malignancy. There is humoral hypercalcemia of malignancy mediated by increased parathyroid hormone-related peptide PTHrh(80%), local osteolytic hypercalcemia(20%) but in hematological tumors, another pathway of overproduction of 1, 25(OH) 2 D3 from tumor cells can cause this accounting for 1% of cases. Hereby we present a case where the only finding was mild splenomegaly and positive 1, 25(OH)2D3 leading to ultimate diagnosis of primary splenic large B cell lymphoma.

Case Description

71-year-old male with past medical history of neuroendocrine tumor of right middle lobe of lung resected 15 years ago with no evidence of recurrence to date, history of mild elevation in PSA with biopsy showing no prostate cancer on 12/12 cores, presented to emergency department with weakness, nausea. Found to have hypercalcemia and AKI. He received pamidronate as an inpatient. His inpatient work up included CT scans (non-contrast), bone scan, skeletal survey that was negative for malignancy. However there was mild splenomegaly (14.1 cm) noted on CT. There were several calcified lymph nodes in the mediastinum as well calcified pleural plaques. Multiple myeloma screening labs were negative. PTHrh was not elevated. Flow cytometry of peripheral blood revealed no abnormalities. TB testing is negative. ACE for sarcoidosis was in normal range. PTH was suppressed. Vit D 1, 25(OH) 2 D3 was elevated at 133. Although no malignancy was found on extensive work up, we strongly felt that it was the most likely cause and referred to oncology. He was discharged after his calcium stabilized around 11. Bone marrow biopsy was done showing no evidence of disease. Finally, PET CT was performed showing a hypermetabolic spleen. He underwent splenectomy on 7/25/2018. Pathology was consistent with primary splenic large B cell lymphoma. His hypercalcemia has completely resolved. He has recovered well from his surgery. He was given standard therapy for diffuse large B cell lymphoma, which is R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). He received 6 cycles of R-CHOP. Post treatment PET scan showed no evidence of disease.

Discussion

Hypercalcemia is rare in patients with B cell NHL, with its insidious presentation requiring urgent treatment. Dedicated evaluation is required in these cases.The presentation with hypercalcemia has a serious impact on prognosis and survival.