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Hypercalcaemia in malignancy
A thread
A thread
Occurs in 20-30% of all cancers
80% due to humoral release of PTHrP which mimicks parathyroid hormone (PTH)
20% due to local osteolytic processes driven by tumour induced cytokines
80% due to humoral release of PTHrP which mimicks parathyroid hormone (PTH)
20% due to local osteolytic processes driven by tumour induced cytokines
Most common in Squamous cell carcinomas, myeloma, breast cancer, lung cancer and renal cancer.
Hypercalcaemia in cancer is a poor prognostic sign: Median survival without treating the underlying cancer is around 40 days and probably less in head and neck cancers
Hypercalcaemia in cancer is a poor prognostic sign: Median survival without treating the underlying cancer is around 40 days and probably less in head and neck cancers
Symptoms are rarely the classic “stones, bones and psychic moans”
A high degree of clinical suspicion is needed. Often the patient is “just not themselves” and family will notice this.
Hypercalcaemia is often confused with opioid toxicity and DYING
A high degree of clinical suspicion is needed. Often the patient is “just not themselves” and family will notice this.
Hypercalcaemia is often confused with opioid toxicity and DYING
Look for
Thirst, polydipsia and polyuria
Thirst, polydipsia and polyuria
Constipation, nausea and anorexia
Confusion and sensitivity to CNS depressants inc opioids
Somnolence and hallucinations
If untreated then seizures, cardiac arrhythmia and death can result
Diagnosis is from history above plus biochemistry findings of
Raised Adjusted calcium >2.60
Low PTH level
Often a raised ALP
If PTH is normal or raised suspect hyperparathyroidism and discuss with endocrinology.
Raised Adjusted calcium >2.60
Low PTH level
Often a raised ALP
If PTH is normal or raised suspect hyperparathyroidism and discuss with endocrinology.
Treatment
Definitive treatment is to treat underlying cancer as hypercalcaemia will usually recur.
Lowering calcium alone wil provide symptomatic relief and improve quality of life but won’t change prognosis from underlying malignancy
Definitive treatment is to treat underlying cancer as hypercalcaemia will usually recur.
Lowering calcium alone wil provide symptomatic relief and improve quality of life but won’t change prognosis from underlying malignancy
Treating high calcium levels can lead to improvement in pain levels so a reduction in analgesia may be possible.
Treating hypercalcaemia in a patient who has a very short prognosis or who has recurrent hypercalcaemia after short intervals needs careful thought.
Treating hypercalcaemia in a patient who has a very short prognosis or who has recurrent hypercalcaemia after short intervals needs careful thought.
Good practice to hydrate first with crystalloid. If evidence clinically or biochemically of dehydration then give 2-3litres of fluid over an appropriate rate for patient.
IV bisphosphonate can then be used to reduce osteoclast activty and lower calcium levels.
IV bisphosphonate can then be used to reduce osteoclast activty and lower calcium levels.
Rapid infusion of bisphosphonate in a dehydrated patient will lead to acute kidney injury.
Warn patient they may experience a fever, nausea and body aches for 24 hours after bisphosphonate infusion.
Don’t recheck serum calcium until day 5-7
Warn patient they may experience a fever, nausea and body aches for 24 hours after bisphosphonate infusion.
Don’t recheck serum calcium until day 5-7
The absolute value of the calcium is less important than how the patient is presenting.
Some patients are exquisitely sensitive to raised calcium levels, especially if it’s an acute rise.
Aim for adj Calcium <2.6 mmol/L by day 7 but be guided by patient progress also
Some patients are exquisitely sensitive to raised calcium levels, especially if it’s an acute rise.
Aim for adj Calcium <2.6 mmol/L by day 7 but be guided by patient progress also
Zolendronic acid will tend to produce a longer lasting reduction in serum calcium than other bisphosphonates.
The dose of bisphosphonate can depend on renal function and calcium level
See here for more info: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/Hypercalcaemia.aspx
The dose of bisphosphonate can depend on renal function and calcium level
See here for more info: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/Hypercalcaemia.aspx
If hypercalcaemia recurs within 2 weeks this is a poor prognostic sign.
Further doses of Zolendronic acid can be given or consideration of the monoclonal antibody Denusomab in selected cases but serk specialist advice.
No treatment may be the right treatment in some
Further doses of Zolendronic acid can be given or consideration of the monoclonal antibody Denusomab in selected cases but serk specialist advice.
No treatment may be the right treatment in some
If hypercalcaemia is refractory to treatment or recurring repeatedly after reducing time intervals then this most likely indicates advanced malignancy with a very short prognosis. Open discussion with the patient and family is vital here
One of the most rewarding moments can be seeing a patient recover from hypercalcaemia and spend quality time with their loved ones.
Without your clinical suspicion and management they would never have woken up.
Add a bone profile to your cancer patient’s bloods
Without your clinical suspicion and management they would never have woken up.
Add a bone profile to your cancer patient’s bloods
