Hypercalcemia of malignancy

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  • 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

Clinical Features

Mnemonic: Stones, Bones, Groans, Moans, Thrones, Psychic Overtones

  • "Stones"
  • "Bones"
    • Bone pain/destruction
  • "Groans"
  • "Thrones"
    • Polyuria/polydipsia (Renal insufficiency)
    • Constipation
  • "Psychic Overtones"

Differential Diagnosis

Causes of Hypercalcemia

Oncologic Emergencies

Related to Local Tumor Effects

Related to Biochemical Derangement

Related to Hematologic Derangement

Related to Therapy


  • Chem10
  • Ionized Ca
  • CBC
  • LFTs (alk phos, albumin)
  • ECG


Asymptomatic or Ca <12 mg/dL

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

Mildly symptomatic Ca 12-14 mg/dL

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

Symptomatic or Severe hypercalcemia (Ca >14 mg/dL)

  • Pts 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]

Electrolyte Repletion


  • 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


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


  • Ca <12
    • Home with follow up if oncology concurs
  • Ca>12
    • Admit ward
  • ECG changes
    • Admit telemetry

See Also


  1. LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.