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Hypercalcaemia in the oncology patient

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Shared care information

Hypercalcaemia in paediatric oncology may be real or spurious (blood sampling problems especially with fragile peripheral leukaemic blasts). Calcium level should be repeated on a fresh sample that is hand delivered to the lab (not via the lansom tube) and spun slowly (discuss with lab). If the hypercalciaemia is real then please discuss with the paediatric oncologist on call before starting treatment.

Causes

Hypercalcaemia is encountered infrequently in paediatric oncology compared with adult practice. However, it is seen in about 0.4% of cases and most often with:

  • Acute lymphoblastic leukaemia
  • Rhabdomyosarcoma
  • Malignant rhabdoid tumour of the kidney
  • Non-Hodgkin's lymphoma
  • Hodgkin's disease
  • Ewing sarcoma
  • Neuroblastoma (due to bone mets or as a complication of cis-retinoic acid therapy)
  • Hepatoblastoma.

Hypercalcaemia is more common in palliative care patients who are more likely to have bone metastases.

As well as being associated with tumour burden or bone and bone marrow invasion it may also be associated with:

  • Immobility
  • Cis-retinoic acid and ATRA
  • Paraneoplastic syndromes (very rare in children)
  • Adrenal insufficiency.

Clinical features

Usually quite non-specific so a high index of suspicion is required:

  • weakness and lethargy
  • nausea and vomiting
  • abdominal pain and constipation
  • polyuria
  • progressing to stupor and coma (seen with levels in children > 3.74 mmol/l).

Diagnosis

A serum calcium level is part of the work up of all patients presenting with a suspected diagnosis of cancer. In many hospitals it is done routinely as part of the pre-determined oncology biochemistry panel. Similarly, the serum calcium level should be determined in paediatric oncology patients when:

  • they relapse or progress
  • during palliative care, when symptoms may suggest hypercalcaemia and it is thought that the patient may benefit from correction of the hypercalcaemia.
  • in patients receiving cis-retinoic acid or ATRA.

If hypercalcaemia is found, also perform ECG looking for shortened QT interval and arrythmias.

Treatment

  • Calcium levels may be factitiously raised by problems with blood sampling, especially in leukaemia with a high white cell count where the fragile cells may leak calcium in the tube. Repeat the sample before initiating aggressive therapy.

  • Cardiac monitoring if Ca > 2.9 mmol/L

  • Hyperhydration (3 litres/m2/24 hours) and frusemide 1 - 2 mg/kg IV. If no improvement in serum calcium after 6 hours give

  • pamidronate (see note below) 0.5 mg/kg IV over 6 hours - if serum Ca++ sustained above 3.24 mmol/L. If there is renal impairment the dose may need to be adjusted - discuss with the renal physician.

  • if indicated, treat the underlying malignancy.

Note: Pamidronate is a potent bisphosphonate, a class of agents which lowers serum calcium by shortening osteoclast survival, and inhibiting osteoclast recruitment and activity. The calcium nadir is seen 6 - 10 days after administration and may last for a month. Check serum calcium and phosphate at least twice weekly as there may be a period of hypocalcaemia (and ↓ serum phosphate) requiring supplementation.
Side-effects include: 'flu-like symptoms - fever, myalgia, CRP, bony aches; eye inflammation, lymphopenia and GIT symptoms. It has also been associated, rarely, with osteonecrosis of the jaw.

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Document Control

  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network