From the Guidelines
Multiple myeloma is the most common malignancy causing hypercalcemia. Hypercalcemia of malignancy occurs in approximately 20-30% of cancer patients during the course of their disease 1. In multiple myeloma, the mechanism typically involves excess bone resorption from bone disease, leading to excessive release of calcium into the blood, contributing to hypercalcemia 1. Symptoms include polyuria and gastrointestinal disturbances, with progressive dehydration and decreases in glomerular filtration rate 1.
Treatment of Hypercalcemia
Treatment typically involves addressing the underlying malignancy while managing the hypercalcemia with:
- Aggressive hydration
- Bisphosphonates like zoledronic acid (4mg IV) or pamidronate (60-90mg IV) 1
- Calcitonin (4-8 IU/kg SC/IM every 12 hours)
- Denosumab (120mg SC) may be used in refractory cases or in patients with renal impairment where bisphosphonates are contraindicated 1
Prevention of Infections
To prevent infections in patients with multiple myeloma, the panel recommends referring to the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections and the CDC recommendations for Use of COVID-19 Vaccines in the United States 1.
Management of Venous Thromboembolism (VTE)
The highest risk for venous thromboembolism (VTE) is in the first 6 months after a new diagnosis of MM. The NCCN MM Panel has outlined management of VTE, risk stratification, and VTE prophylaxis in a separate section in the NCCN Guidelines for MM 1. Some key points to consider in the management of multiple myeloma and hypercalcemia include:
- Plasmapheresis should be used as adjunctive therapy for symptomatic hyperviscosity 1
- Erythropoietin therapy may be considered for patients with anemia, especially those with renal failure 1
- Measuring endogenous erythropoietin levels may also be helpful in treatment planning 1
From the Research
Causes of Hypercalcemia
- Hypercalcemia of malignancy affects up to one in five cancer patients during the course of their disease 2
- It is associated with both liquid malignancies, commonly multiple myeloma, leukemia, and non-Hodgkins lymphoma and solid cancers, particularly breast and renal carcinomas as well as squamous cell carcinomas of any organ 2
- Breast cancer has the highest prevalence of hypercalcemia among all cancer in females 3
Prevalence of Hypercalcemia in Cancer Patients
- Hypercalcemia occurs in approximately 10-30% of all patients with neoplastic disease 4
- It is the most common life-threatening metabolic disorder associated with cancer 4
- Hypercalcemia is most common in those who have later-stage malignancies and predicts a poor prognosis for those with it 5
Most Common Malignancy Causing Hypercalcemia
- Breast cancer is the most common malignancy causing hypercalcemia, with approximately 70% of patients with breast cancer having bone metastases and 10% of them will have hypercalcemia as a complication at some point in the disease 3
- Other common malignancies causing hypercalcemia include multiple myeloma, leukemia, and non-Hodgkins lymphoma, as well as solid cancers such as renal carcinomas and squamous cell carcinomas of any organ 2