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Diagnosis and Treatment > Medication

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Nikolaos Asonitis National and Kapodistrian University of Athens, First Department of Internal Medicine, Laikon Hospital, School of Medicine, Athens, Greece
Msc Metabolic Bone Diseases, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

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Eva Kassi National and Kapodistrian University of Athens, First Department of Internal Medicine, Laikon Hospital, School of Medicine, Athens, Greece
Msc Metabolic Bone Diseases, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

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Michalis Kokkinos National and Kapodistrian University of Athens, First Department of Internal Medicine, Laikon Hospital, School of Medicine, Athens, Greece

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Ilias Giovanopoulos National and Kapodistrian University of Athens, First Department of Internal Medicine, Laikon Hospital, School of Medicine, Athens, Greece

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Foteini Petychaki National and Kapodistrian University of Athens, First Department of Internal Medicine, Laikon Hospital, School of Medicine, Athens, Greece

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Helen Gogas National and Kapodistrian University of Athens, First Department of Internal Medicine, Laikon Hospital, School of Medicine, Athens, Greece

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Summary

Hypercalcemia of malignancy is the most common cause of hypercalcemia in hospitalized patients. It is associated with a poor prognosis, since it reflects an advanced cancer stage. Among all cancer in females, breast cancer is the most common malignancy, and it has the highest prevalence of hypercalcemia. Approximately 70% of patients with breast cancer have bone metastases and 10% of them will have hypercalcemia as a complication at some point in the disease. Herein, we report a 69-year-old female patient with metastatic breast cancer, who developed severe hypercalcemia in the course of her disease and was diagnosed with humoral hypercalcemia of malignancy (HHM). Intense hydration along with corticoisteroids and antiresorptive medication (calcitonin, bisphosphonates and denosumab) were administered to the patient. Despite the above treatment, serum calcium levels remain elevated and calcimimetic cinacalcet was added. Upon discontinuation of cinacalcet, calcium levels were raised and returned back to the normal levels following re-initiation of the calcimimetic. Her calcium level restored to normal, and she was discharged with the following medical treatment: denosumab monthly, and cinacalcet at a titrated dose of 90 mg per day. The patient is followed as an outpatient and 11 months later, her calcium level remained within the normal range.

Learning points:

  • Hypercalcemia of malignancy is the most common cause of hypercalcemia in hospitalized patients.

  • Breast cancer has the highest prevalence of hypercalcemia.

  • The cornerstone of therapy remains the intense hydration and intravenous bisphosphonates (preferably zoledronic acid).

  • In case of persistent hypercalcemia of malignancy, the administration of calcimimetic cinacalcet could be an additional effective therapeutic option.

Taxonomy:
Clinical Overview, Gland/Organ, Bone, Topic, Tumours and neoplasia, Hormone, Calcitonin, PTH, Condition/ Syndrome, Breast cancer, Hypercalcaemia, Hypothyroidism, Patient Demographics, Age, Geriatric, Gender, Female, Ethnicity, White, Country of Treatment, Greece, Diagnosis and Treatment, Signs and Symptoms, Constipation, Malaise, Myasthaenia, Nausea, Polyuria, Skin - texture change, Tachycardia, Vomiting, Xerostomia, Investigation, Alkaline phosphatase, Calcifediol, Calcitriol, Calcium (serum), Creatinine, Electrocardiogram, Magnesium, Phosphate (serum), PTH, Intervention, Chemotherapy, Fluid repletion, Mastectomy, Radiotherapy, Medication, Bisphosphonates, Calcimimetics, Calcitonin, Cinacalcet, Corticosteroids, Denosumab, Furosemide, Glucocorticoids, Hydrocortisone, Methylprednisolone, Saline, Zoledronic acid, Related Disciplines, Oncology, Publication Details, Case Report Type, Novel treatment
DOI:
https://doi.org/10.1530/EDM-17-0118
Volume/Issue:
Volume 2017: Issue 1
Open access
Reiner Jumpertz von Schwartzenberg Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Ulf Elbelt Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Manfred Ventz Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Knut Mai Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Tina Kienitz Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Lukas Maurer Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Thomas Rose Division of Rheumatology and Clinical Immunology, Medical Department, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Jens C Rückert Department of General Visceral Vascular and Thoracic Surgery, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Christian J Strasburger Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Joachim Spranger Department of Endocrinology and Metabolic Diseases, Charité – Universitätsmedizin, Charitéplatz 1, Berlin, 10117, Germany

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Parathyroid carcinoma is a rare disease leading to severe hypercalcemia due to hyperparathyroidism. Surgery is the primary treatment option. A more progressive form of the disease is characterized by parathyrotoxicosis, and subsequent hypercalcemia is the most common cause of death. We report a case presenting with severe hypercalcemia due to parathyrotoxicosis from parathyroid carcinoma treated for the first time using the monoclonal antibody denosumab as a rescue therapy and present long-term follow-up data. The 71-year-old patient presented with severe hypercalcemia due to metastatic parathyroid carcinoma. Despite undergoing treatment with bisphosphonates, cinacalcet hydrochloride, and forced diuresis, the patient`s condition deteriorated rapidly due to resistant hypercalcemia. Surgery performed because of spinal metastasis and forced diuresis lowered calcium levels, albeit they remained in the hypercalcemic range and significantly increased when forced diuresis was stopped. Considering a palliative situation to overcome hypercalcemia, we decided to administer denosumab, a monoclonal antibody that binds to the receptor activator of nuclear factor-kappa B ligand. After a single subcutaneous administration of 60 mg denosumab, calcium levels normalized within one day. Subsequent denosumab injections led to permanent control of serum calcium for more than 2 years despite rising parathyroid hormone levels and repeated surgeries. Together with recent cases in the literature supporting our observation, we believe that denosumab is relevant for future trials and represents an effective tool to control hypercalcemia in patients with advanced stages of parathyroid cancer.

Learning points

  • Severe hypercalcemia is the most common cause of death in patients with parathyroid carcinoma.

  • The monoclonal antibody denosumab rapidly lowered severely elevated serum calcium levels due to parathyrotoxicosis.

  • Denosumab was effective in the long-term treatment of hypercalcemia despite progression of parathyroid carcinoma.

Taxonomy:
Clinical Overview, Gland/Organ, Parathyroid, Topic, Endocrine disruptors, Hormone, PTH, Condition/ Syndrome, Hypercalcaemia, Metastatic carcinoma, Parathyroid carcinoma, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, Germany, Diagnosis and Treatment, Signs and Symptoms, Abdominal pain, Appetite reduction/loss, Back pain, Bony metastases, Bowel obstruction, Cachexia, Constipation, Hypercalcaemia, Nausea, Weight loss, Investigation, Calcium (serum), CT scan, PET scan, PTH, Intervention, Resection of tumour, Medication, Bisphosphonates, Calcimimetics, Cinacalcet, Denosumab, Diuretics, Furosemide, Sodium chloride, Zoledronic acid, Related Disciplines, General practice, Nephrology, Oncology, Surgery, Publication Details, Case Report Type, Novel treatment
DOI:
https://doi.org/10.1530/EDM-15-0082
Volume/Issue:
Volume 2015: Issue 1
Open access