Hypercalcemia of Malignancy
This chapter discusses hypercalcemia of malignancy which is the commonest biochemical complication of cancer and recognized as a medical emergency. Hypercalcemia presents with a wide range of clinical symptoms which in some cases can be severe and life-threatening. It is essential for clinicians to consider hypercalcemia as a differential diagnosis in patients with nonspecific symptoms, as hypercalcemia is potentially reversible. The following sections will review normal calcium homeostasis and discuss the mechanisms of how cancer disrupts this tightly regulated system. It is recognized that hypercalcemia is normally associated with advanced disease and, unless antineoplastic treatments are available, is a poor prognostic sign. It is therefore important to consider the individual clinical situation before deciding on an appropriate management plan. Hypercalcemia results in hypovolemia, and the initial management should consist of rehydration. Following this, specific calcium-lowering treatment should be considered. Following rehydration, bisphosphonates have been the treatment of choice for the last 20 years and are effective in the initial treatment for the majority of cases. Unfortunately, it is common for hypercalcemia to relapse, and the best approach to treatment of recurrent and refractory hypercalcemia is not clear. Denosumab is an emerging option, and the initial evidence appears favorable. Further research regarding the use of denosumab for hypercalcemia of malignancy is warranted.
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