Hypercalcemia

By Dr. Sumayya Latif

 Definition
• Hypercalcemia occurs in 20–30% of patients with
advanced solid tumours
• Hypercalcaemia occurs when corrected calcium is
greater than 2.6 mmol/L (10.5 mg/dl)
• Hypercalcaemia of malignancy is the commonest
cause of hypercalcaemia in inpatients
• Hypercalcaemia of malignancy carries a poor
prognosis
 Corrected calcium
• Corrected serum calcium (mg/dL) =
measured calcium + 0.8(4.0 – measured albumin)
 Pathogenesis
• In patients with osteolytic metastases: due to
increased bone resorption and release of calcium
from bone
• In patients without bone metastases: secondary to
circulating factors such as parathyroid hormone-
related peptide (PTH-RP) or 1,25-
dihydroxyvitamin D (calcitriol).
• However, it is important also to remember that
patients with cancer may also have incidental
primary hyperparathyroidism
 Presentation
Early symptoms
1. Polyuria, nocturia, polydipsia
2. Anorexia
3. Easy fatigability
4. Weakness

Late symptoms
1. Apathy, irritability, depression, decreased ability to
concentrate, coma
2. Profound muscle weakness
3. Nausea, vomiting, vague abdominal pain, constipation,
obstipation, increased gastric acid secretion, acute
pancreatitis
4. Pruritus
5. Abnormalities of vision
 Investigations
• Serum-corrected calcium level
• Electrolytes
• Renal biochemistry
• Phosphate and magnesium levels and PTH
• ECG:
Increased PR interval or widened QRS.
 Corrected ca++ < 3mmol/L or
Asymptomatic pt

• Asymptomatic patients with a corrected calcium of

less than 3.0 mmol/L who are about to have
chemotherapy or radiotherapy should be
rehydrated, kept mobile and monitored
regularly.
• Patients who are symptomatic or who are expected
to have a slow response to anti-cancer treatment
should be treated as follows.
 Corrected ca++ > 3mmol/L or
Symptomatic pt
• Fluid replacement:
Give at least 3 L NaCl 0.9% in 24 hours.
• Correct hypokalaemia and hypomagnaesia if
present
• Be careful to watch for fluid overload if the patient
has evidence of cardiac or renal failure. Aim for a
urine output of 100–150 mL/h.
• Stop thiazide diuretics.
• Furosemide does increase calcium excretion but
should not be given until dehydration has been
treated
Bisphosphonates
• Inhibit calcium release by interfering with osteoclast-
mediated bone resorption
• Zoledronic acid has a fast onset and a long duration
of action. Ensure adequate hydration before giving)
Dose: 4 mg in at least 50 mL of either NaCl 0.9% or
glucose 5% over 15 minutes.
Monitor renal function and serum calcium, phosphate
and potassium. Be careful if there is known renal
impairment, which may require a reduced dose or
slower infusion rate
• Side effects of bisphosphonates include
gastrointestinal upset, flu-like symptoms and
exacerbation of metastatic bone pain.
Osteonecrosis of the mandible can occur after
chronic use.
• Hypocalcaemia occurs in 50% of patients, but it
rarely causes symptoms because of a
compensatory increase in PTH levels secondary to
the decreased calcium levels
 Other drugs
• Calcitonin increases renal calcium excretion and decreases
bone resorption.
Salcatonin has a very rapid onset and may be used in patients
with dangerously high serum calcium levels, regardless of
fluid status. Tachyphylaxis develops, so the effectiveness of
salcatonin is limited.
• Gallium nitrate inhibits osteoclastic bone resorption and
inhibits PTH secretion
• Mithramycin
• Consider dialysis in patients with severe hypercalcemia if
the prognosis is good but adequate hydration cannot be
administered because of cardiac or renal failure
Malignant Cord
Compression
 Etiology
Caused by:
• pressure from a tumor (growing directly between
vertebral bodies or growing from bone
metastases)
• a collapsed vertebral body on the spinal cord or
cauda equina
Cause paraparesis, or paraplegia, loss of sensation
and bladder or bowel dysfunction
• Associated with : breast cancer, lung cancer,
prostate cancer and multiple myeloma
• Patients at increased risk of developing bone
metastases or patients with diagnosed bone
metastases should be informed about the
symptoms of metastatic cord compression
 Presentation
ØS & S will depend on the level of compression.
• Compression above L1: upper motor neuron pattern
of weakness
• Compression below L1: a lower motor neuron
pattern of weakness
ØMuscle weakness >> Sensory loss >> Autonomic
dysfunction
ØRadicular pain : Approx. 60% pts
ØAsymptomatic cord compression : 1/3rd pts with
prostate cancer and bone mets
 Investigations
• MRI with contrast of the whole spine: within 24
hours of presentation to detect the level of
compression
• Patients not previously diagnosed with cancer -->
Important to establish a tissue diagnosis if
possible (e.g. by needle biopsy or during surgical
decompression)
 Initial Treatment
• Dexamethasone: 16 mg daily in divided doses with
PPIs protection
Precautions while giving steroids:
• Given with PPIs
• Reducing the dose after a few days to avoid toxicity
• Taper the dose when leaving
• If neurological function deteriorates at any time the
dose should be reconsidered
• Blood sugar levels should be monitored
• Adequate analgesia
• Thromboprophylaxis: Reduced mobility
• Nurse the patient in the supine position if there is
any possibility of spinal instability
• Patients require a multidisciplinary approach
including specialist physiotherapy and nursing
care.
 Surgery

ØIn selected patients with a single area of MSCC

from a solid tumor, the benefit of immediate
circumferential decompression of the spinal
cord--> followed by radiotherapy >>> superior to
radiotherapy alone

ØMore paraplegic patients gained the ability to walk

following surgery as opposed to radiotherapy-only
group
ØTokuhashi scoring system can be helpful in making
a decision for spinal surgery
ØSpinal surgery should also be considered:
• If there is a need to obtain histology
• If there is spinal instability
• If pain has not been controlled despite adequate
analgesia
 Radiotherapy
• Radiotherapy is the most commonly used
treatment of MSCC.
• Aim to give radiotherapy within 24 hours of the
confirmed diagnosis of spinal cord compression.
 Simulation Technique
• Position: prone or supine, with arms by the side
• Immobilization: Knee support and/or head support
may be used
• Localization: simulator films are taken at the level of
spinal cord compression
Target volume: Level of compression + one vertebral
body above and below this level
• Ensure that the inferior and superior limits cross an
intervertebral space
• Typically, the field borders are defined at the time of
simulation.
 Plan
Fields:
• Single posterior field
• Upper cervical cord compression: opposed lateral
fields to avoid having the exit beam pass through
the throat and mouth
• A typical field length for a posterior treatment field
would be 10–15 cm
• The center of the field is in the midline along the
spinous processes and is usually 8 cm wide
• Dose:
• 20 Gy / 5 daily Fx
30 Gy / 10 daily Fx
• Given as either an applied dose or prescribed at
the depth of the spinal cord (determined using
MRI)
• Single 8 Gy Fraction appropriate for a patient
with poor prognosis and established neurological
defcit
• Energy: 6 MV photons / C0-6o
 Relative contraindications to
radiotherapy
• No histological diagnosis of cancer
• Relatively radio resistant tumour, if surgery is an
option (renal carcinoma, sarcoma, melanoma)
• Cord compression is due to vertebral
displacement/spinal instability
• Previous radiotherapy to same spinal site
• Poor general condition due to other major and
irreversible clinical problems
• Prognosis likely to be less than 1- 2 months
 Outcome
• Outcome was related to the length of time over
which the motor deficit developed before
radiotherapy, with more than 14 days being better
than a shorter time interval
• Patients who are ambulatory after treatment have
a median survival of 8 to 9 months, whereas
median survival is 1 month for nonambulatory
patients.
• Improvement in motor function in 14% of patients,
no change in 54%, and deterioration in 32%