Hypercalcemia of malignancy

• PTHrP release
  • SCC (particularly of the head and neck), breast renal, endometrial cancer
• Local osteolysis
  • Associated primarily with bone mets
  • Multiple myeloma, lung, breast cancer
• Production of vitamin D analogues
  • Lymphoma (Hodgkin)

• Addison's disease
• Calciphylaxis
• Excess vitamin D
• Hypercalcemia of malignancy
• Hyperparathyroidism
• Hyperthyroidism
• Hypothyroidism
• Lithium
• Milk-alkali syndrome
• Paget disease
• Sarcoidosis
• Thiazide diuretics

• Malignant airway obstruction
• Bone metastases and pathologic fractures
• Malignant spinal cord compression
• Malignant Pericardial Effusion and Tamponade
• Superior vena cava syndrome

• Hypercalcemia of malignancy
• Hyponatremia due to SIADH
• Adrenal insufficiency
• Tumor lysis syndrome
• Carcinoid syndrome

• Neutropenic fever
  • Neutropenic enterocolitis (typhlitis)
• Leukostasis and hyperleukocytosis
• Hyperviscosity syndrome
• Thromboembolism

• Chemotherapy-induced nausea and vomiting
• Cytokine release syndrome
• Chemotherapeutic drug extravasation
• Differentiation syndrome (retinoic acid syndrome) in APML
• Stem cell transplant complications
• Catheter-related complications
  • Tunnel infection
  • Exit site infection
  • CVC obstruction (intraluminal or catheter tip thrombosis)
  • Catheter-related venous thrombosis
  • Fracture of catheter lumen
  • Oncologic therapy related adverse events

• Does not require immediate treatment
• Advise to avoid factors that can aggravate hypercalcemia (thiazide diuretics, Li, volume depletion, prolonged inactivity, high Ca diet)

• May not require immediate therapy; however, an acute rise may cause symptoms necessitating treatment as described for severe hypercalcemia (see below)

• Patients are likely dehydrated and require saline hydration as initial therapy

• Isotonic saline at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour

• Consider adding calcitonin 4 units/kg SC or IV q12hr in patients w/ Ca >14 mg/dL (3.5 mmol/L) who are also symptomatic (lowers Ca w/in 2-4hr)
• Tachyphylaxis limits use long term, but is a great choice for emergent cases

Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)

• Pamidronate 90mg IV over 24 hours OR
• Zoledronate 4mg IV over 15 minutes
• Caution in renal failure, though bisphosphonates have been safely used in pts with pre-existing renal failure[1]

• Correct hypokalemia
• Correct hypomagnesemia

• Furosemide is NOT routinely recommended
• Only consider in patients with renal insufficiency or heart failure and volume overload

Consider if patient:

• Anuric with renal failure
• Failing all other therapy
• Severe hypervolemia not amenable to diuresis
• Serum Calcium level >18mg/dL
• Neurologic symptoms

Decrease Ca mobilization from bone and are helpful with steroid-sensitive tumors (e.g. lymphoma, MM)

• Prednisone 60mg PO daily