Endocrine Abstracts (2003) 5 P36

Clear cell ovarian adenocarcinoma presenting with parathyroid hormone-related protein-dependent hypercalcaemia

T Abdalla1, G Rieck2, S Leeson2, D Wayte3, A Owen4, C Adams5 & A Wilton1

1Department of Diabetes and Endocrinology, Ysbyty Gwynedd, Bangor, UK; 2Department of Obstetrics and Gynaecology, Ysbyty Gwynedd, Bangor, UK; 3Department of Pathology, Ysbyty Gwynedd, Bangor, UK; 4Department of Clinical Biochemistry, Ysbyty Gwynedd, Bangor, UK; 5Department of Radiology, Ysbyty Gwynedd, Bangor, UK.

A previously well 46-year-old nulliparous woman presented with nausea, polydipsia, polyuria, nocturia, loss of appetite, weight loss of 3 months and secondary amenorrhoea of 9 months duration.
Examination revealed the presence of a mass apparently arising from the pelvis, this being confirmed by CT scanning. Investigations: calcium 4.3millimols per litre, phosphate 0.8millimols per litre, albumin 45grams per litre, parathyroid hormone <0.6picomols per litre (1.6-6.9), glucose 5.5millimols per litre, angiotensin converting enzyme 13 international units per litre (20-54), vitamin D2 <4 micrograms per millilitre (0-10), vitamin D3 19nanograms per millilitre (5-25), parathyroid hormone related protein 18.9 picomols per litre (<1.8), CA125 49 units per litre (<35) and CEA 2nanograms per millilitre (<3). Urea, electrolytes and creatinine were normal. Chest x-ray normal.
Initial treatment with intravenous fluids and pamidronate had little effect on calcium levels. At laparotomy a 12cm-left ovarian tumour was found. Hysterectomy, bilateral salpingo oophorectomy and infracolic omentectomy sampling were performed. Postoperative recovery was complicated by severe symptomatic hypocalcaemia requiring treatment with intravenous calcium infusions followed by oral calcium supplements and alphacalcidol. Histology confirmed stage 1c clear cell adenocarcinoma of ovary with invasion of capsule and presence of malignant cells in the peritoneal fluid. Two weeks postoperatively calcium was 2.1millimols per litre and parathyroid hormone 7.3picomols per litre therefore calcium supplements were stopped. At 4 weeks calcium was 2.4millimols per litre and alphacalcidol was also stopped. Adjuvant chemotherapy is planned.
This case describes the unusual presentation of ovarian carcinoma with symptomatic hypercalcaemia secondary to high levels of parathyroid hormone related protein. Surgical removal of the tumourous source of parathyroid hormone related protein resulted in symptomatic hypocalcaemia as endogenous parathyroid gland function was suppressed.

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