Hypercalcaemia and elevated levels of parathyroid hormone-related protein in cutaneous squamous/basal cell carcinoma

Humoral hypercalcaemia of malignancy associated with a gigantic cutaneous squamous cell carcinoma

Humoral hypercalcaemia of malignancy is rarely associated with cutaneous squamous cell carcinoma (SCC), and only a few cases have been reported in the medical literature. We present an interesting case of a gigantic cutaneous SCC associated with severe hypercalcaemia.A man in his mid 80s presented with a rapidly enlarging fungating mass of his scalp for 5 months. Laboratory studies logged severe hypercalcaemia, low intact parathyroid hormone, elevated parathyroid hormone related-peptide and normal 1,25 dihydroxy vitamin D. Skin biopsy revealed moderately differentiated invasive SCC. Further workup was negative for distant skeletal metastases. Severe hypercalcaemia was managed by intravenous fluids, bisphosphonates and calcitonin. A multidisciplinary approach was then made; the patient received radiotherapy and then underwent a successful surgical resection. By presenting this case, we aim to raise physicians' awareness of the association between cutaneous SCC and hypercalcaemia. Severe hypercalcaemia should be detected early and promptly managed as it could be fatal.

Paraneoplastic Syndromes in Patients with Keratinocyte Skin Cancer

Simple Summary

The aim of the present review is to compile and evaluate the literature data on paraneoplastic syndromes (PNS) associated with keratinocyte skin cancer (KSC). Forty relevant entries were assembled, reporting a total of 41 PNS cases associated with a KSC (34 male). No review paper compiling this topic was found. Six distinct PNS entities were identified, and malignancy associated hypercalcemia (MAH; 78%), anemia (10%) and Bazex syndrome (5%) were the most frequently reported among them. 85% of the PNS were reported in association with SCC, 10% with BCC, and the rest with adnexal tumors. The median age of the patients at the time of PNS diagnosis was 58 years (range: five–83 years). KSC predisposing conditions, as scars (22%) or hidradenitis suppurativa (20%), were reported in >70% of the PNS cases. In conclusion, PNS are rarely reported in association with KSC, possibly reflecting a limited capacity of KSC to provoke overt PNS.

Abstract

A variety of well-characterized cutaneous paraneoplastic syndromes (PNS) are diagnosed during internal malignancies; however, the spectrum of keratinocyte skin neoplasms (KSC) related to PNS is still obscure. The aim of the present review is to compile and evaluate the literature data on PNS associated with a keratinocyte skin neoplasm (KSC). Employing Pubmed, MEDLINE was searched for KSC-associated PNS reports. Forty relevant entries were assembled, reporting a total of 41 PNS cases associated with a KSC (34 male). No review paper compiling this topic was found. Six distinct PNS entities were identified, and malignancy associated hypercalcemia (MAH; 78%), anemia (10%) and Bazex syndrome (5%) were the most frequently reported among them. 85% of the PNS were reported in association with SCC, 10% with BCC, and the rest with adnexal tumors. The median age of the patients at the time of PNS diagnosis was 58 years (range: five–83 years). In most cases the PNS was diagnosed either concurrently or after the KSC diagnosis. KSC predisposing conditions, as scars (22%) or hidradenitis suppurativa (20%), were reported in >70% of the PNS cases. Most PNS resolved after KSC treatment. In conclusion, PNS of a rather limited spectrum of entities are reported in association with KSC. They also seem to be rare, possibly reflecting a limited capacity of KSC to provoke overt PNS.

PTH-independent hypercalcaemia and non-melanoma skin cancer

BACKGROUND

Recently, it became more evident that skin is a target for neuroendocrine signals.

AIMS

(1) To evaluate the relationship between tumour aggressiveness and hypercalcaemia in patients with non-melanoma skin cancer; (2) to identify clinical, functional, biological alterations caused by this setting; (3) calcium redistribution from extracellular fluids to intracellular compartments; (4) to describe several molecular aspects of hypercalcaemia development.

MATERIALS AND METHODS

This study was conducted between January 2000 and May 2009 in Dermatoveneorological Center, Bucharest. From the 1232 cases that were investigated, there were 32 patients with keratoachantoma, 468 patients with basal cell carcinoma, 412 patients with squamous cell carcinoma and 320 healthy volunteers. All the patients were screened by clinical and paraclinical examinations (haematology, biochemistry, immunology). After biochemical confirmation of hypercalcaemia, patients had endocrine tests, electrocardiography and imagistic approaches. Total serum calcium was measured in extracellular fluids (serum, urine) by spectrophotometric methods. Ionized calcium was calculated depending on total serum calcium and total proteins. Corrected serum total calcium (cTCa) levels were calculated using albumin and total serum calcium levels. In tumour tissues and intact skin, calcium was assayed by physical methods of analysis: Instrumental Neutron Activation Analysis (INAA), Proton-Induced X-ray Emission (PIXE). Intact PTH was measured by ELISA.

RESULTS

PTH-independent hypercalcaemia prevalence is low in SCC patients (1.21%). Hypercalcaemia manifestations are multiple including: digestive, renal, neuromuscular, and cardiovascular abnormalities. In these patients, intact PTH (iPTH) is normal, urinary calcium is decreased, serum albumin is reduced, and calcium concentration in tumour tissue is significantly increased compared to healthy tissue.

CONCLUSIONS

PTH-independent hypercalcaemia has a low prevalence in SCC patients. Hypercalcaemia is correlated with susceptibility to develop metastases in SCC. A possible mechanism is PTHrp hypersecretion by malignant keratinocytes.

Alternative splicing of parathyroid hormone-related protein mRNA: expression and stability

Parathyroid hormone-related protein (PTHrP) is a multifunctional protein that is often dysregulated in cancer. The human PTHrP gene is alternatively spliced into three isoforms, each with a unique 3'-untranslated region (3'-UTR), encoding 139, 173 and 141 amino acid proteins. The regulation of PTHrP mRNA isoform expression has not been completely elucidated, but it may be affected by transforming growth factor-beta1 (TGF-beta1). In this study, we examined differences in the PTHrP mRNA isoform expression in two squamous carcinoma cell lines (SCC2/88 and HARA), an immortalized keratinocyte cell line (HaCaT), and spontaneous human lung cancer with adjacent normal tissue. In addition, the effect of TGF-beta1 on PTHrP mRNA isoform expression and stability was examined. Cell-type specific expression of PTHrP mRNA isoforms occurred between the various cell lines, normal human lung, and immortalized human keratinocytes (HaCaT). PTHrP isoform expression pattern was significantly altered between normal lung tissue and the adjacent lung cancer. In vitro studies revealed that TGF-beta1 differentially altered the mRNA steady-state levels and mRNA stability of the PTHrP isoforms. Protein-RNA binding studies identified different proteins binding to the 3'-UTR of the PTHrP isoforms (139) and (141), which may be important in the differential mRNA stability and response to cytokines between the PTHrP isoforms. The data demonstrate that there is cell-type specific expression of PTHrP mRNA isoforms, and disruption of the normal regulation during cancer progression may in part be associated with TGF-beta1-induced changes in PTHrP mRNA isoform expression and stability.

Messenger RNA stability of parathyroid hormone-related protein regulated by transforming growth factor-beta1

Humoral hypercalcemia of malignancy (HHM), a paraneoplastic syndrome associated with epithelial cancers, including squamous cell carcinoma (SCC), is due to expression and secretion of parathyroid hormone-related protein (PTHrP). Transforming growth factor-beta1 (TGFbeta1), expressed by many tumors, has been demonstrated in vitro to increase the half-life of PTHrP mRNA. In this study, oral squamous carcinoma cells (SCC2/88) had a two-fold increase in PTHrP mRNA stability (from 45 to 90 min) in response to treatment with TGFbeta1. In order to examine the mechanism of TGFbeta1-mediated PTHrP mRNA stability, a cell-free assay of mRNA degradation was utilized in which the degradation of in vitro-transcribed mRNA incubated with cytoplasmic protein extracts from SCC2/88 treated with vehicle or TGFbeta1 was measured. In this assay, full-length PTHrP mRNA was not significantly stabilized in TGFbeta1-treated samples when compared to vehicle treated samples. However, there was a striking (>5-fold) increase in PTHrP mRNA half-life in TGFbeta1-treated samples when PTHrP mRNA lacked the 3'-untranslated region (3'-UTR). In contrast, the degradation of 3'-UTR-truncated PTHrP mRNA using the cell-free assay was not altered in vehicle-treated samples. UV cross-linking of PTHrP mRNA and cytoplasmic proteins from cells treated with either vehicle or TGFbeta1 revealed numerous mRNA-binding proteins. TGFbeta1 treatment resulting in decreased binding of 33, 31, 27, 20 and 18 kDa binding proteins to the terminal coding region. These studies revealed that TGFbeta1-induced PTHrP mRNA stability might be, in part, the result of cis-acting sequences within the coding region of the PTHrP mRNA.

Head and neck squamous cell carcinoma: measurement of plasma parathyroid hormone-related protein and serum and urine calcium concentrations

OBJECTIVES

Parathyroid hormone-related protein (PTHrP) is expressed by squamous cell carcinomas. Our first objective was to examine the stability of PTHrP in normal human plasma. Our second objective was to determine whether plasma PTHrP could be used in patients with head and neck squamous cell carcinoma (HNSCC) as an indicator of tumor burden or relapse.

STUDY DESIGN AND SETTING

Blood and urine samples from 55 HNSCC patients undergoing tumor resection at The Ohio State University were measured for plasma PTHrP (1-86) concentration, serum ionized calcium concentration, and urine calcium/creatinine ratio.

RESULTS

Two of 55 HNSCC patients had detectable levels of plasma PTHrP. Serum ionized calcium concentrations and urinary calcium/creatinine ratios were within normal limits in all patients.

CONCLUSIONS

Plasma PTHrP was not a valuable indicator of tumor presence or recurrence in our patient population.

SIGNIFICANCE

Plasma PTHrP is not a useful marker of tumor presence or recurrence in patients with stage II to IV or recurrent HNSCC.

Immunohistochemical detection of parathyroid hormone-related protein in a cutaneous squamous cell carcinoma causing humoral hypercalcemia of malignancy

Humoral hypercalcemia of malignancy is a cancer-related hypercalcemia caused by production of humoral factors by malignant cells in patients without bone metastases. Squamous cell carcinomas are the tumors most frequently associated with humoral hypercalcemia of malignancy, and parathyroid hormone-related protein is the main humoral factor implicated. In spite of the fact that normal keratinocytes produce parathyroid hormone-related protein, it is highly unusual for patients with squamous cell carcinomas of the skin to present with humoral hypercalcemia of malignancy. We present a well-documented case of cutaneous squamous cell carcinoma complicated by hypercalcemia in a patient with high levels of plasma parathyroid hormone-related protein and immunohistochemical evidence of high parathyroid hormone-related protein production by the tumoral cells.

Advanced cutaneous squamous cell carcinoma of the trunk and extremity: analysis of prognostic factors

BACKGROUND

Patients with squamous cell carcinoma (SCC) of the skin may exhibit locally advanced or metastatic disease and present a challenging management problem.

METHODS

A retrospective review of 40 patients with advanced SCC of the trunk or extremity managed at Roswell Park Cancer Institute from 1982 through 1992 was performed to identify clinical and pathologic factors that influenced outcome.

RESULTS

There were 27 males and 13 females with a median age of 61 years. Median follow-up was 24 months. Surgical resection to control the primary tumor was often extensive. Amputation was required in nine patients, hemipelvectomy in three patients, and hemicorporectomy in one patient. Median survival was 28 months, and 5-year survival was 43%. Univariate analysis identified stage (P = 0.04), size (P = 0.0001), type of surgical procedure (P = 0.009), and margins of resection (P = 0.005) as having prognostic significance. On multivariate analysis, stage (P = 0.04) and size (P = 0.02) were found to be significant.

CONCLUSIONS

Optimum treatment for advanced SCC of the trunk and extremity involves surgical resection with uninvolved margins. The role of elective node dissection remains undefined. Investigation is needed to define the role of neoadjuvant therapy that may improve functional and cosmetic results.

Humoral hypercalcemia of malignancy with elevated plasma PTHrP, TNF alpha and IL-6 in cutaneous squamous cell carcinoma

A case of humoral hypercalcemia of malignancy in cutaneous squamous cell carcinoma is reported. An 82-year-old male underwent surgery for cutaneous squamous cell carcinoma (SCC) of the left hand in 1992. He subsequently developed clouding of consciousness with remarkable hypercalcemia, a high parathyroid hormone related protein (PTHrP) level, and elevated plasma cytokine levels [tumor necrosis factor alpha (TNF alpha), interleukin-6 (IL-6)]. Diagnosis of humoral hypercalcemia of malignancy (HHM) was made on the basis of these findings. He died of renal insufficiency due to this hypercalcemia in spite of several replacement therapies and chemotherapies. The PTHrP might have derived from the SCC and have been responsible for the HHM in conjunction with IL-6 and TNF alpha.