The document discusses the management of malignant hypercalcemia and spinal cord compression in cancer patients, highlighting symptoms, diagnosis, and treatment options. Malignant hypercalcemia can lead to poor prognosis and requires fluid replacement and bisphosphonates, while spinal cord compression necessitates urgent recognition and may involve steroids, radiation, or surgery. Overall, early intervention can significantly improve patient outcomes and quality of life.

1. Oncology

2. Case 1
• 70 male with HL with widespeard bone mets not responding
to oncological treatmnet
• Presented with
– nausea and vomiting
– increase urination and constipation
– abdominal pain
• Wife reports- less active than usual
• when you saw him he appears to be twitchy
• decided to admit him for investigation and management

3. Bloods
• normal UEG
• Calcium level 3.4

4. Malignant hypercalcaemia
• occurs in 10-30% of patient with cancer
• carries poor prognosis
• life expectancy < 6 months
• 50 % die within 30 days of diagnosis
• commonly seen in
– breast , NSCLC, prostate, MM, lymphoma

6. Malignant hypercalcaemia
two main cause
Humoral hypercalcaemia of malignancy 80%
• Tumour secreted substances- PTHrP (parathyroid hormone related peptide), Vit
D analogues TNF-alpha
– PTHrP -increased bone resorption and renal tubular resorption of calcium -> serum
hypercalcaemia
– commonest cancer is SCC of any origin- head, neck, lung
– other cancer include breast, ovarian, lymphoma, renal , NET
• 1,25 -dihydroxy Vit D (Vit D analogue)- increase intestinal absorption of
calcium
– All HL, 1/3rd of NHL
Local bone destruction-lytic bone mets 20%
– Breast and MM

7. Presentation

8. Management of hypercalcaemia
Points to consider prior to treatment
• First episode or long interval since previous episode.
• Patient reports good quality of life prior to episode.
• Multidisciplinary team expectation is that treatment will
have durable effect.
• Patient is willing and able to have intravenous treatment
and blood tests.
• Treatment may not be appropriate in a dying patient at the
end of life ->seek advice.

9. Management
• The aim of treatment is to improve symptoms and reduce
corrected calcium level to within the normal range.
• IV fluid replacement and IV bisphosphonates are
treatments of choice.
• To reduce risk of renal toxicity from bisphosphonate
treatment, consider withholding medication that affects
the renal function (for example non-steroidal anti-
inflammatory drugs, diuretics, thiazide diuretics,
angiotensin-converting enzyme inhibitors)

10. • Mild hypercalcemia <3mmol/l in asymptomatic or mildly
symptomatic
– Avoid factors that can aggravate hyperCa
• Thiazide diuretic, volume depletion, prolonged bed rest or immobility,
high calcium diet >1000mg/day, Xs vitamin D supplement >800IU/day
– Adequate hydration
• Moderate 3-3.5mmol/l
– Chronic will not require immediate rx
– Acute typically treat with hydration +/- bisphophonate

11. • Severe >3.5mmol/l, require aggressive rx
– IV hydration
– SC/IM calcitonin 4 units/kg
• Can be repeated every 12 hours for total duration 24-48hrs. If response
not satisfactory, may increase dosage to 8 units/kg every 6-12 hrs
– Bisphophonate (typically zoledronic acid)
– For patients in whom bisphosphonates are contraindicated 
denosumab
• Consider HD if > 4.5

12. Treatment
• sodium chloride 0.9% 4 to 6 litres by intravenous infusion
over 24 hours.
Additional Treatment
• zoledronic acid 4 mg by intravenous infusion over at least
15 minutes
OR
• pamidronate 60 to 90 mg by intravenous infusion over 4
hours; starting dose depends on total serum calcium
concentration corrected for albumin.

15. Points to remember
• Not all symptoms resolve after treatment. This may be due to other cause(s)
or underlying disseminated disease.
• Bisphosphonates may cause mild flu-like symptoms.
• Bisphosphonates are implicated risk factors in osteonecrosis of the jaw,
osteonecrosis of the auditory canal and atypical fractures.
• Where possible, patients should have regular dental checks and avoid
invasive dental procedures whilst on treatment.
• The severity of symptoms is related to the rate of increase; not the level of
corrected calcium.
• The speed of recurrence may signify a poor prognosis.
• Review current treatments for underlying disease.
• Untreated severe hypercalcaemia can be fatal.

16. Case
• 58 lady with T2N2 NSCLC diagnosed 18 months ago
• Completed palliative chemoradiotherapy
• went ED with 5 weeks of increasing back pain
• describe a band of pain encircling the body and it is
commonly made worse by coughing or straining
• radiation down Right leg with tingling and numbness
• Examination WNL exception right leg pain with SLR
positive

17. Imaging

18. Malignant spinal cord compression
• Usually results form extension from spinal
bony mets
• compress thecal sac of spinal cord
• frequent complication of malignancy
• pain is most common presenting sx

19. MLSCC
• relative common
• 2.5-5% of cancer pts
• most common with
– breast, lung, prostate Ca (15-25%
– renal, lymphoma, MM (5-10%)
• location
– 70% thoracic
– 20% lumbar
– 10% cervical
• multiple levels involved in 1/3 of pts

20. Clinical features
• 90% back pain
– characteristic: pain worsened by supine or with percussion of
vertebral bodies “band” pain that tends to worsen on coughing
or straining
• pain precedes neurological sx
• early recognition leads to better outcomes
• delay-> paralysis and inontinence

21. Mx
• Pain control
• pharmacological Rx
• surgery
• radiation
• start steriods ASAP as Dx made/suspected
• if suspects urgent MRI: gold standard (95% sensitive,
97% specificity)

22. Pharmacological Rx
• Steroids for initial Rx
• helps restore neurologic fx and prevent permanent
damange
• steroids tapered as definitive Rx started

23. Initial
• dexamethasone 16 mg orally or intravenously, as a single
dose OR dexamethasone 16 mg subcutaneously, in 2
divided doses at separate injection sites
Continuation
• IV dex 16mg daily or 8mg BD , if no benefit cease after 5
days

24. Radiation
• standard therapy for non surgical candidate
• brief radiotherapy may be offered for with shorter life
expectancy
• eg of radiosensitive tumour
– breast
– MM
– prostate
– lymphoma

25. Surgery
• Criteria
– life expectancy > 3/12, performance status, neurologic damage
< 48 hours
– single area tumour
– can be indicated for non-radiosensitive tumour and unstable
spine/ #/ bony compression
• decompressive therapy + post op radiotherapy better

26. Chemotherapy
• consideration for chemosensitive tumour
– NHL
– HL
– Germ cell tumour

27. Late/ Pall Care Stage
• steroids alone
• symptomatic mx

28. Outcomes of treatment
• 70% of patients who were ambulant at the time of
diagnosis will regain the ability to walk.
• 30% of patients with paraparesis will regain the ability to
walk.
• 5% of patients with established paraplegia will regain the
ability to walk.