Current Medicinal Chemistry, 2008, 15, 415-421 415

0929-8673/08 $55.00+.00 2008 Bentham Science Publishers Ltd.

Medical Treatment of Malignancy-Associated Hypercalcemia
F. Lumachi*
,1
, A. Brunello
2
, A. Roma
2
and U. Basso
2
1
Department of Surgical and Gastroenterological Sciences, University of Padua, School of Medicine, 35128 Padova, Italy
2
Division of Medical Oncology, Istituto Oncologico Veneto (IOV), IRCCS, 35128 Padova, Italy
Abstract: Malignancy-associated hypercalcemia (MAH) is the commonest cause of hypercalcemia in hospitalized patients. Its incidence
is 15 cases per 100,000 person-year. Such complication develops in almost 10% of patients with advanced cancer representing, ulti-
mately, the most frequent cause of death in several patients with cancer. Parathyroid hormone related protein (PTHrP), which has strong
homology to parathyroid hormone, is the commonest hormonal mediator of MAH. Overall, about 80% of patients with MAH have in-
creased PTHrP serum levels. Bisphosphonates are synthetic analogues of pyrophosphate, and represent the principal support of treatment.
Several bisphosphonates have shown to decrease serum calcium levels by inhibiting PTH-dependent osteoclast activation. They are po-
tent and effective inhibitors of osteoclast-mediated bone resorption, and have shown antiangiogenic properties in some experimental
models. At present, pamidronate, zoledronate and ibandronate should be considered the drugs of choice in the treatment of MAH. Old
agents such as mithramycin, calcitonine, and gallium nitrate have practically been abandoned due to their limited activity and huge side
effects, especially for the kidney. A new experimental approach to MAH involves the blockade of receptor activator of nuclear factor-
kappa B ligand, usually abbreviated as RANKL. RANKL is a key element in the differentiation, function, and survival of osteoclasts,
which plays an essential role in removing Ca
++
from the bone in response to PTH stimulation. This review provides information about
the actual medical treatment of MAH.
Keywords: Malignancy-associated syndrome, hypercalcemia, bisphosphonates, parathyroid hormone related protein, PTHrP, cancer therapy,
paraneoplastic syndrome, malignancy.
INTRODUCTION
Malignancy-associated hypercalcemia (MAH) is the most
common paraneoplastic endocrine syndrome, occurring in 10-15%
of malignancies, and ultimately represents the cause of death in
several patients with cancer [1-3]. MAH is the commonest cause of
hypercalcemia in hospitalized patients, with an incidence of about
15 cases per 100,000 person-year. MAH usually occurs in advanced
malignancy (i.e. lung and breast cancer, multiple mieloma), and
thus its prognosis is very poor, with a median survival of only few
months [1, 2, 4]. However, both in patients with breast carcinoma
and in those with multiple myeloma and MAH, successful therapy
for underlying malignancy may provide long-term survival [5].
Most solid tumors can be associated with hypercalcemia, as shown
in Fig. (1). However, hypercalcemia is particularly seen in those
arising from epithelial tissues, in which parathyroid hormone re-
lated protein (PTHrP) is the commonest cause of MAH. This pro-
tein, which has strong homology to parathyroid hormone (PTH),
binding with equal affinity to bone and kidney PTH receptors, is
produced in many normal fetal and adult tissues [1, 6, 7]. Overall,
about 80% of patients with MAH may have increased PTHrP serum
levels [3, 5].
PATHOPHYSIOLGY
In cancer patients three different mechanisms may lead to de-
velop hypercalcemia [8, 9]:
1. Replacement of normal bone marrow by metastatic cancer cells
or malignant plasma cells. The degradation of bone matrix
through release of cytokines, chemokines and prostaglandins,
justify the appearance of osteolytic or, less frequently, os-
teoblastic radiological alterations. The growth of neoplastic
cells into the bone is maintained and amplified by the so called
vicious cycle. Both normal and malignant bone and he-
mopoietic marrow cells interact together with a complex net-
work of agents (i.e. interleukin-1 [IL-1], IL-6, and tumor necro-
sis factor alpha [TNF-]) with paracrine effects, enhanced can-
cer growth and osteoclast activation as ultimate outcome.


*Address correspondence to this author at the Department of Surgical & Gastroen-
terological Sciences, University of Padua, School of Medicine, via Giustiniani 2, 35128
Padova, Italy; Tel: +39 049 821 1812; Fax: +39 049 656 145;
E-mail: flumachi@unipd.it
2. The secretion of PTHrP by cancer cells, with or without direct
bone involvement, activates osteoclasts in the entire skeleton.
PTHrP is a small protein with substantial homology with N-
terminal aminoacid sequence of PTH, which is transcribed from
a different gene and then translated into different isoforms due
to alternative splicing of mRNA [8]. PTHrP may have both
paracrine and systemic effects, parallel to those of PTH on the
bone and kidney, by means of activation of the same receptors
(PTH/PTHrP receptor), and possess an amino-terminal domain
homologous with PTH [1, 8, 10]. Thus, PTHrP influences bone
resorption, the renal capacity to reabsorb both calcium and
phosphates, and the synthesis of 1,25-dihydroxyvitamin D
[1,25(OH)
2
D
3
] and of cyclic AMP [11]. However, its physio-
logical role is quite different from that of PTH, because PTHrP
regulates the development of skin, hair follicle and mammary
gland [1, 11].
3. Abnormal conversion of cholecalciferol (vitamin D
3
) to
1,25(OH)
2
D
3
within lymphoma cells, causing increased intesti-
nal absorption of calcium. This mechanism is less frequent.
The first mechanism is prevailing in MAH correlated with
squamous cell carcinoma of the lung, head & neck cancer, or renal
carcinoma. MAH with skeletal involvement is common in patients
with multiple myeloma and breast cancer, and less frequent in lung
and prostate cancer, but the extent of bone involvement is not pro-
portionally correlated with the severity of hypercalcemia.
Distinction of a humoral versus osteolytic form of MAH has
currently limited practical application: the two mechanisms are
often coexisting in the same patient because also patients with bone
metastases often display increased circulating levels of PTHrP [8].
Activation of Receptor Activator of Nuclear Factor-kappaB Ligand
(RANKL), produced by either tumor cells, stromal cells or cells of
the immune system on response to PTHrP or IL, is another key
process in MAH and will be briefly discussed along with possible
pharmacological interventions.
DIAGNOSIS
In hypercalcemic patients, several symptoms and signs are usu-
ally reported, enclosed neuromuscular (weakness, hypertonia), car-
diovascular (hypertension, bradycardia), renal (polyuria, renal
stones), gastrointestinal (nausea, vomiting), and central nervous
system (i.e. depression, lethargy, ataxia, psychosis) effects but,
unfortunately, none are specific.
416 Current Medicinal Chemistry, 2008 Vol. 15, No. 4 Lumachi et al.
In the differential diagnosis of MAH the first step is serum PTH
measurement, with the aim of excluding primary hyperparathyroid-
ism (HPT) in which, typically, there are high PTH levels, especially
in patients with parathyroid cancer [12]. This tumor represents a
rare cause of HPT, accounting for only 1-5% of cases. It is usually
easy to localize but difficult to diagnose because no reliable preop-
erative immunohistochemical markers are available [13-15]. In non
hyperparathyroid patients, the physiological defense against hyper-
calcemia is suppression of PTH secretion, with subsequent transi-
tory reduction of both bone resorption and production of 1,25(OH)
2

D
3
, and increase of calcium excretion [16]. In patients with MAH,
PTH serum levels are usually low, and the severity of symptoms
should be increased in respect to those with other causes of hyper-
calcemia. The onset of the syndrome is earlier, due to cancer-
related symptoms, concomitant chemotherapy or analgesic thera-
pies [17]. However, in cancer patients with whole body scanning
showing bone metastases, the early administration of bisphospho-
nates for the prevention of skeletal-related events may reduce the
incidence of clinically symptomatic hypercalcemia in the clinical
practice [18]. MAH may be suspected using the standard biochemi-
cal tests usually performed in all cancer patients as a part of routine
care. Hypercalcemia may occasionally be also the first sign of a
multiple myeloma, or represent a paraneoplastic syndrome associ-
ated with occult solid cancer (i.e. squamous-cell carcinoma of the
tracheo-bronchial tract or upper gastro-esophageal system, clear-
cell carcinoma of the kidney, hepatocarcinoma). In all patients with
advanced metastatic cancer, measurements of serum albumin and
total proteins should be performed, because also normal calcium
levels may mask an occult MAH, especially in those with solid
tumors. Algorithms for albumin-corrected calcium values have
been proposed, but they are seldom employed in the clinical prac-
tice [19]. The quantification of ionized calcium may be a more
accurate parameter for this purpose. Some authors recommend to
check routinely the level of PTH in order to rule out the coexistence
of primary hyperparathyroidism [9]. The determination of circulat-
ing PTHrP is usually not necessary, with the exception of patients
with normal bone scintigraphy in whom a non-malignant cause of
hypercalcemia is suspected [17]. Markers of bone resorption such
as N-terminal eight-aminoacid peptide produced by the osteoclastic
cathepsin K on bone collagen I (NTX), and C-terminal fragment of
collagen I (CTX) are frequently increased in patients with bone
metastases, as well as markers of concomitant osteoblastic activa-
tion (i.e. bone-specific alkaline phosphatase [BSAP]), but they can-
not replace the bone scanning and other radiological exams for the
early diagnosis of bone metastases [20].
MEDICAL TREATMENT
Hypercalcemia is usually accompanied by different degrees of
dehydration due to the inhibition of water reabsorption at the distal
tubule in the kidney, and is worsened by vomiting and decreased
liquid intake induced by the concomitant nausea.
Vigorous hydration with 0.9% saline solution is the currently
cornerstone of treatment along with intravenous bisphosphonates,
although a durable clinical improvement cannot be achieved with-
out active treatment of the underlying cancer. Depending upon the
severity of dehydration and the cardiovascular health of the patient,
up to 500 mL per hour can be infused in the first hours until ade-
quate urine output has been established, and then reduced to 2-3 L
daily in the following days. Volume expansion dilutes calcium
concentration (usually in the range of 1 to 2 mg/dL) but does not
interfere with osteoclastic function and, if employed alone, is inef-
fective in restoring normocalcemia. In fact, hyperhydration was
demonstrated to be inferior to bisphosphonates in randomized trials
[17].
Loop diuretics enhance calcium excretion in the kidney but
should be used only after normovolemia has been reached, other-
wise they might worsen dehydration as well as induce hypokalemia.
Concomitant treatments should be reviewed in order to eliminate
interfering drugs such as thiazide diuretics (which increase renal
calcium reabsorption), lithium or supplementation of calcium and
vitamin D for a concomitant osteoporosis.
Steroid hormones (i.e. prednisone) are sometimes employed in
order to reduce intestinal calcium absorption and hypercalcemia-
related nausea as well as to improve concomitant cancer-related
symptoms. Unfortunately, their real contribution to the reduction of
calcium level is of marginal relevance with the exception of pa-
tients with multiple myeloma or lymphoma, in whom they have a
direct antineoplastic activity [9, 17].
BISPHOSPHONATES
Bisphosphonates are synthetic analogues of pyrophosphate, in
which the central atom of oxygen (P-O-P) has been replaced by a
carbon atom (P-C-P), to which the two phosphate groups and two










Fig. (1). Primary site of cancer causing malignancy-associated hypercalcemia.
Malignancy-Associated Hypercalcemia Current Medicinal Chemistry, 2008 Vol. 15, No. 4 417
additional organic chains (R1 and R2) are covalently bound.
Bisphosphonates were long known since the late 19
th
century in
textile and fertilizer industries due to their anti-corrosive properties.
Etidronate was the first bisphosphonate to be used an a patient with
myositis ossificans at the end of the 60s [21, 22]. Pyrophosphate is
able to inhibit in vitro both the formation and dissolution of calcium
phosphate complexes, contrasts ectopic calcifications in vivo, but it
has a low oral bioavailability and undergoes rapid hydrolysis by
pyrophosphatases after intravenous infusion. Therefore, analogues
resistant to these enzymes were developed such as the bisphospho-
nates. Clodronate, pamidronate, zoledronate and ibandronate are
currently used in patients with MAH and this review will concen-
trate on them. These compounds differ in terms of chemical struc-
ture, oral bioavailability and other pharmacokinetic parameters, as
well as potency of bone resorption inhibition and toxic effects, es-
pecially on the kidney [23, 24]. All these bisphosphonates rapidly
decrease calcium levels in hypercalcemic patients through inhibi-
tion of bone resorption with superimposable mechanisms. Unlike
calcitonin and gallium nitrate, they do not have a direct activity on
tubular calcium resorption in the kidney.
Some bisphosphonates have displayed also anti-tumor and
antiangiogenic properties in some cell cultures and animal models,
with inhibition of binding and invasion of human prostate and
breast cancer cells to mineralized and unmineralized matrices, as
well as growth inhibition of cancer cell lines and synergy with cyto-
toxic agents [25-27]. However, the contribution of these properties
to the management of acute MAH may be considered of marginal
relevance.
When given at high doses, bisphosphonates inhibit soft tissue
calcifications formation in patients with scleroderma or dermato-
myosistis, as well as those undergoing hip replacement, and may
decrease calculi formation in urolithiasis. An impairment of normal
mineralization of bone and cartilage has also been shown, accom-
panied by a homeostatic decrease of circulating calcitriol as a re-
sponse of more availability of serum calcium [28].
At lower doses bisphosphonates inhibit bone resorption, an ef-
fect which has been demonstrated in experimental models, healthy
individuals and patients with different conditions of abnormal bone
metabolism (i.e. Pagets disease, osteoporosis, primary and secon-
dary HPT). Studies with radioactive calcium (
45
Ca) have proved
that bisphosphonates increase calcium deposition in the extracellu-
lar matrix, as well as they are able to counteract the bone loss
pharmacologically induced by PTH, calcitriol and retinoids [29].
Indeed, the molecules of bisphosphonates remain entrapped within
the mineralized tissue, becoming thus inactive until released by
further bone remodeling and incorporated into osteoclasts. At a
molecular level, bisphosphonates interfere with homeostasis of
calcium phosphate solutions by direct binding onto calcium phos-
phate complexes. The two oxygen atoms of each phosphonate
group plus the hydroxyl group on the R1 lateral chain are attracted
by the positive charges of calcium ions, thus blocking both growth
and dissolution of the complexes themselves. This explains why
bisphosphonates in vitro inhibit the transformation of amorphous
calcium phosphate into hydroxyapatite crystals as well as prevent
the precipitation of calcium phosphate from clear solutions [22].
Molecular mechanism of antiresorptive activity in vivo is much
more complex, involving inhibition of osteoclasts as well as modu-
lation of activity of ostoblasts and macrophages, which is reached at
lower doses compared to those necessary to interfere with dissolu-
tion of calcium crystals. The bone exposed to bisphosphonates
shows reduction of resorptive cavities, and reduction in the number
of osteoclasts, with signs of reduced activity and increased apopto-
sis.
It is usually believed that bisphosphonates may act adhering di-
rectly on osteoclast surface or entering these cells by pinocytosis
thus hampering adhesion to the mineralized matrix, altering the
morphology as well as the cytoskeleton, reducing lysosomal en-
zymes and eventually triggering pro-apoptotic pathways [22, 30].
Moreover, bisphosphonates are able to inhibit osteoclastic differen-
tiation from monocyte-macrophage progenitors and recruitment to
the resorptive cavities, although this effect may be mediated by
involvement of other cells such as osteoblasts which produce an
osteoblastic-derived inhibitor of osteoclasts [31]. Increased prolif-
eration of osteoblasts and enhanced collagen synthesis have been
demonstrated in vitro, but the clinical relevance of such action has
not been proved so far [32]. Since complete blocking of bone re-
sorption hampers normal bone remodeling and repair of microfrac-
tures, it is not unusual that prolonged treatment with very high
doses of bisphosphonates in animals are associated with increased
bone fragility as that seen in osteopetrosis [33]. These effects are
absent when doses comparable to those used in cancer patients are
considered.
Potency of antiresorptive activity has a wider range of variation
in different compounds compared to inhibition of mineralization,
therefore more potent molecules without a concomitant risk of in-
terference with normal mineralization have been made available.
Indeed, decreased bone resorption is accompanied by a concomitant
reduction of new bone formation, but as a consequence of a delayed
response of homeostatic mechanisms of bone remodelling or a true
imbalance of the resorptive function, a positive calcium and bone
balance may be achieved in patients receiving bisphosphonates
[34]. Attempts have been made to correlate structural changes of
the molecules with antiresorptive potency, which increases progres-
sively with the length of the R2 aliphatic side chain on the central C
atom. Starting from a single methyl group in etidronate, activity is
progressively enhanced if a chloride (clodronate), a nitrogen (pa-
midronate and alendronate), pyridinylic (risendronate), 3-
methylpentylamino-propylidene (ibandronate) or imidazolic group
(zolendronate) has been added. Nitrogen-containing bisphospho-
nates are capable of inhibiting the mevalonate pathway in osteo-
clasts, resulting in altered post-translational modification (prenyla-
tion) of proteins with guanosine triphosphatase activity (such as
Ras), altered cellular functions and, ultimately, activation of prote-
olytic enzymes implied in apoptotic processes such as the caspases
[30, 35].
Additional extra-skeletric effects of bisphosphonates include
damage on gastroesophageal mucosa (usually encountered with oral
compounds), increase in plasma high-density lipoproteins and im-
munological alterations such as diminished monocytic-macrophagic
activation and secretion of cytokines plus impairment of both T and
B cell immune response if given at high doses [22]. Due to the
negative charge, most bisphosphonates, with the exception of clo-
dronate and ibandronate, have a very low oral bioavailability. After
intravenous injection, they bind to plasma proteins but are rapidly
absorbed by the bone due to the higher affinity with hydroxyapatite
crystals, with a conspicuous first passage effect. They accumulate
preferably in the sites of new bone formation and under osteoclasts
in resorptive cavities, and after incorporation in the bone mineral
matrix, they may be slowly released with a half-life of some years
in man [22]. Due to the rapid extraction from the plasma and mini-
mal exposure of peripheral tissues, little toxicity has been usually
described using bisphosphonates in the treatment of MAH [24].
Transitory hypocalcemia or hypophosphatemia is usually of
marginal clinical relevance, while self-limiting fever may develop
for a few days after first injection as a consequence of release of
cytokines (mainly IL-6 and TNF-alfa) by macrophages.
The risk of renal toxicity differs among the compounds and is
very low with ibandronate compared to pamidronate and especially
zoledronate [24]. Prompt rehydration of the patient and slower rate
of infusion are recommended in order to avoid the formation of
solid-phase complexes, which might acutely damage the kidney and
eventually induce acute tubular necrosis [36].
418 Current Medicinal Chemistry, 2008 Vol. 15, No. 4 Lumachi et al.
The development of osteonecrosis of the jaw is a serious com-
plications recently described in patients treated with bisphospho-
nates, especially in myeloma patients after long treatment with
pamidronate or zoledronate or those with recent teeth extractions or
other invasive interventions on the jaw or maxilla bone [37]. En-
quiry on current dental health is therefore mandatory before treat-
ment and the pros and cons of using bisphosphonates in patients
with active dental problems must be carefully weighted taking into
consideration the severity of MAH (calcium levels and symptoms)
as well as the prognosis of the patient (tumor stage and availability
of active systemic treatments).
Etidronate
Etidronate has an hydroxyl group on R1 and a methyl group on
R2, and has been given both orally and intravenously. A single 30
mg/kg infusion over 24 hours has been given to patients with MAH,
but reduction of calcium levels was achieved after a mean of 4
days. Synergy with calcitonin has been reported, but randomized
comparisons with both pamidronate, and gallium nitrate clearly
proved inferior efficacy of etidronate, thus limiting the use of this
bisphosphonate in the treatment of MAH [38-41].
Clodronate
The molecule of clodronate has a chloride atom at both R1 and
R2 lateral chains, and is available both for oral and intravenous use.
High doses of oral clodronate (1.600 mg/daily) have been adminis-
tered to patients with both multiple myeloma, and breast cancer [42,
43]. A reduction in the number of hypercalcemic episodes was ob-
served, but the risk of gastrointestinal toxicity with so high doses
and the superior activity of intravenous bisphosphonates contraindi-
cate their use. A single 1,500 mg infusion over 4 hours has been
demonstrated to control MAH in around 80% of patients, with an
earlier response compared to refracted intravenous doses 300
mg/daily for 5 days [44]. In a head-to-head comparison with pa-
midronate, intravenous clodronated showed less activity (normocal-
cemia achieved in 80 vs. 100% of patients) as well as shorter dura-
tion of effect (median normocalcemia duration 14 vs. 28 days). A
second comparative trial showed that MAH relapsed significantly
earlier with clodronate compared to pamidronate [45]. Moreover,
two patients failing clodronate responded to pamidronate [46]. Also
the intravenous formulation of clodronate is currently considered as
a drug of second choice.
Pamidronate
Pamidronate has a terminal NH
2
group on the R1 ethylic chain
and can be administered only intravenously. From 0.5 to 1.5 mg/kg
were administered to patients with MAH, achieving normocalcemia
in more than 80% of patients in early trials [47]. A clear dose-
response has been demonstrated, because doses of 30, 60 and 90 mg
normalized calcium levels in 30%, 61% and 100% of patients pre-
treated with 48-hour hydration, respectively [48]. Infusion time was
72 or 24 hours in early trials, but then was shortened at four or two
hours, without significant increment of nephrotoxicity [49, 50]. As
cited elsewhere in the text, randomised trials proved that pamidro-
nate is superior to clodronate and etidronate, as well as to mitramy-
cin [39, 45, 46, 51]. Gallium nitrate proved to be at least as effec-
tive as pamidronate in patients with MAH [52].
Zoledronate
Zoledronate, with an imidazolic group on R2 lateral chain, is
for exclusive intravenous use. This bisphosphonate is 10,000 fold
more potent than etidronate in inhibiting bone resorption in rats and
has the widest literature concerning its antiresorptive and anti-
tumoral properties [22, 27]. A dose-finding study demonstrated that
doses as low as 0.02 mg/kg may normalize calcium levels in pa-
tients with MAH within 2 to 3 days, and this effect which may last
from two to three weeks according to the dosage employed [53].
Another phase I study demonstrated that at least 2 mg of zoledro-
nate are needed to suppress markers of bone resorption, but 4 to 8
mg are much more effective, therefore these two dosages were cho-
sen for phase III trials [54]. Zoledronate (either 4 or 8 mg by 5-
minute infusion) was compared against 90 mg pamidronate (2-hour
infusion) in two double-blind, randomized studies on MAH which
were then published as a pivotal pooled analysis [55]. Rate of nor-
mocalcemia at day 10, duration of response and time to relapse
were considered as primary end points. A total of 275 cancer pa-
tients with mean serum calcium level of 3.47 mmol/L (range 3.00-
5.16 mmol/L) were treated. At the primary day 10 analysis, normo-
calcemia was achieved in 88.4% and 86.7% of cases treated with 4
or 8 mg zoledronate, respectively, compared to 69.7% with pa-
midronate (p<0.01). On day 4, almost half of patients on zoledro-
nate arms were already normocalcemic compared to one third of
those on pamidronate. Duration of normocalcemia was superior
with zoledronate (32 days with 4 mg, 43 days with 8 mg of zole-
dronate vs. 18 days with pamidronate). Sixty-nine patients refrac-
tory to 4 mg zoledronate or pamidronate were re-treated with 8 mg
zoledronate, with 52% of normal calcium level at day 10, and a
median duration of response of 15 days. The incidence of fever
(33% to 44.2%), nausea (21.4% to 29.1%), dyspnea (18.4 to 22.1%)
and asymptomatic hypocalcemia or hypophosphatemia appeared to
be equivalent in the three arms, while grade 3-4 creatinine increase
was somewhat higher with zoledronate (7.5% overall) compared to
pamidronate (4%). Moreover, the effect of zoledronate was inde-
pendent of gender, age, tumor type, presence of absence of bone
metastases or serum level of PTHrP, while response with pamidro-
nate appeared to be higher in patients with bone osteolytic lesions
(80%) compared to those with different lesions (61%). The authors
concluded that zoledronate is superior to pamidronate in the rate
and duration of control of MAH, 4 mg is the recommended dose for
initial treatment of MAH while the higher dose can be used in re-
lapsing or refractory patients [55]. The 69% of response to pa-
midronate in this trials is lower compared to 80- 100% of former
trials, but higher that 59% reported by others [46-48, 52]. Differ-
ences among different trials may be attributed to patient selection
bias (type of cancer and severity of MAH) as well as different time
of bisphosphonate administration (with or without 24-48 hours of
preparative hyper-hydration) and time and modality heterogeneity
in assessing response of calcium levels. The potential nephrotoxic-
ity of zoledronate depends upon dose and infusion rate since ran-
domised trials employing longer infusion time of zoledronate, such
as 15 minutes, did not report increased risk of renal toxicity as
compared to placebo [56]. Close creatinine clearance monitoring is
recommended in patients treated with zoledronate, since the product
label suggests stepwise dose reductions for creatinine clearance
levels of 50-60 mL/min (3.5 mg), 40-50 (3.3 mg), 30-40 (3 mg),
and contraindicates the use of this bisphosphonates if creatinine
clearance is below 30 ml/min, and/or other nephrotoxic drugs are
given to the patient [18].
Ibandronate
Ibandronate has a tertiary nitrogen group on R2 lateral chain
which enhances its antiresorptive properties. The drug is available
both for intravenous or oral use, with currently recommended doses
of 6 mg infusion every three or four weeks or 50 mg/daily, although
only the intravenous formulation has been studied for the treatment
of hypercalcemia [57]. Doses ranging from 0.2 to 6 mg of ibandro-
nate have been given by 1-hour infusion to patients with MAH,
achieving control of hypercalcemia in 70% of patients, starting
from the next day of infusion with a nadir around the fifth day [58,
59]. A dose-response association was evident in patients receiving 2
or 4 or 6 mg of ibandronate, although median time to calcium nor-
malization and median duration of response appeared to be compa-
Malignancy-Associated Hypercalcemia Current Medicinal Chemistry, 2008 Vol. 15, No. 4 419
rable [58-60]. Breast or hematological cancer predicted higher re-
sponse, while the severity of hypercalcemia did not appear to be
univocally correlated with reduced or increased response across
different trials [59]. In a randomized trial ibandronate showed com-
parable percentages of response against pamidronate (76.5% vs.
75.8%) and mean calcium level reduction (0.6 mmol/L vs. 0.41
mmol/L) , but median duration of response appeared to be longer
for the former drug (14 vs. 4 days, p<0.05) [59]. Yet, it must be
noted that different dosages of both drugs were employed, thus
creating a serious bias in the above comparisons of activity among
the two drugs. The safety profile of ibandronate appears favorable
with around 10% of acute phase reaction after intravenous infusion
and occasional flu-like symptoms, with an extremely low rate of
nephrotoxicity [24]. Moreover, ibandronate has been given to pa-
tients with mild creatinine increase with no relevant consequences
on renal function, thus it may represent the bisphosphonate of
choice for individuals with moderate renal impairment or those
receiving concomitant nephrotoxic drugs, with no need for dose
reduction [18].
NON-BISPHOSPHONATE DRUGS
Mythramicin, gallium nitrate, calcitonin and calcium-chelating
agents were used before the advent of bisphosphonates and are
currently considered obsolete for the treatment of MAH, although
some of them may still constitute an option for salvage treatment of
refractory patients.
Mithramycin (Plicamycin) is a cytotoxic agent used in the 70s
due to its ability to inhibit bone resorption through blocking of
RNA synthesis in osteoclasts [61]. It was administered as a slow 4-
to 6-hour infusion of a single dose of 25 g/kg, with response start-
ing within 12 hours and reaching a maximum at 48 hours and then
fading. Repeated doses were required at 3- to 7-day intervals. Ad-
verse side effects were common: myelosuppression (thrombocy-
topenia more frequent), increased liver transaminases and renal
failure. A randomized trial comparing mithramycin against pa-
midronate in 48 patients demonstrated a significantly inferior per-
centage of success in achieving normocalcemia at 1 week (45 vs.
88%, p<0.01) along with a shorter normocalcemia duration and
increased incidence of vomiting (36 vs. 0%). Mithramycin was
therefore judged less effective and convenient for patients com-
pared to the bisphosphonate [51].
Gallium nitrate was initially studied for its antineoplastic prop-
erties and then accumulation in the bone and inhibition of extra-
cellular matrix resorption were discovered. The mechanisms are not
fully elucidated, but reduced solubilization of hydroxyapatite crys-
tals and direct inhibition of osteoclasts have been proposed, as well
as reduced tubular renal resorption [62]. The most common dosage
is 100 to 200 mg/m
2
given by continuous intravenous infusion over
five days. Nausea/vomiting, hypophosphatemia and potential neph-
rotoxicity have been associated with this agent [41]. In a random-
ized, double-blind comparison with high dose salmon calcitonin (8
IU/kg every 6 hours for 5 days, intra-muscular), a 5-day treatment
with gallium nitrate achieved higher rates of normocalcemia (75%
vs. 30.7%, p<0.01) as well as longer duration of normocalcemia
before other hypocalcemic or antineoplastic treatment (6 vs. 1 days,
p<0.01) in 50 evaluable patients [63]. Another randomized double
blind trial compared gallium nitrate with etidronate (7.5 mg/kg
daily, 1 to 5) and superior rate of calcium normalization (82 vs.
43%, p<0.01) and longer duration of normocalcemia (8 vs. 0 days,
p<0.01) were reported with the first agent [41]. Comparing pa-
midronate (60 to 90 mg) to gallium nitrate 200 mg/m
2
daily for 4
days in 64 patients with MAH, and reported 56 vs. 69% of success
in achieving normocalcemia, which lasted for a median of 10 days
with pamidronate and 14 days for gallium nitrate, with no evidence
of nephrotoxicity [52]. No randomized comparisons with zoledro-
nate are available, but the need for 5-days continuous infusion has
probably limited further clinical assessment of this agent in favor of
bisphosphonates with shorter infusion. Currently gallium nitrate can
be considered only for the treatment of patients with severe MAH
refractory to bisphosphonates, with the exception of patients with
primary hyperparathyroidism in whom inhibition of PTH secretion
induced by this agent has occasionally been reported [62].
Calcitonin is a polypeptide hormone which binds to specific re-
ceptors located on the surface of bone and renal cells. Physiologi-
cally, calcitonin enhances renal excretion of calcium and inhibits
bone resorption in response to increased plasma levels of calcium.
A derivative of salmon calcitonin may be administered subcutane-
ously or by intra-muscolar injection, at the dose of 100 to 400 UI,
three times a day for one or more days according to the severity of
hypercalcemia. Calcium starts to recede within 6 to 12 hours but
then tends to rise again after a few days due to the occurrence of
tachyphylaxis of receptors. The reduction of calcium level is rarely
superior to 1 mg/dl and this fact, along with the transient efficacy,
explains why calcitonin is currently a drug of second choice. Some
authors have administered calcitonin along with a bisphosphonate,
observing synergistic interaction and a more rapid fall of calcium
levels compared to the bisphosphonate alone, but the increasing
costs limited a wide application of this combined approach [38, 64].
Since calcitonin side effects are only occasional flushing and nau-
sea but not renal toxicity, its use might be of particular relevance
for patients with kidney failure unable to receive pamidronate or
zolendronate, maybe in combination with corticosteroids as previ-
ously reported, although the availability of non-nephrotoxic
bisphosphonates such as ibandronate should be considered as well.
Response of MAH to calcitonin in a patient refractory to bisphos-
phonates has recently been reported [65, 66]. Other alternatives
occasionally employed in the treatment of MAH are agents able to
bind calcium and remove it from extracellular fluids, such as phos-
phate and EDTA [67].
Oral or intravenous supplementation of phosphate has been
used in the past in patients with hypercalcemia because it is able to
form insoluble complexes with calcium, which then accumulate in
the bone or soft tissues [68]. Since high dose of phosphate may
precipitate renal failure, induce seizures, abnormal cardiac conduc-
tion and diarrhea, and promote ectopic calcifications, its use in the
clinical practice is discouraged, with the only theoretical exception
of patients with concomitant severe hypophosphatemia [9].
ROLE OF RANKL IN MAH AND NEW TREATMENT AP-
PROACHES TO MAH
The RANKL system is the central pathway leading to osteoclast
differentiation and activation and bone resorption in MAH, and
currently represents the most promising target for the development
of new treatments of MAH [9, 69]. RANKL is a transmembrane
protein belonging to the TNF super-family and was previously
known also as TNF-related activation-induced cytokine (TRANCE)
or osteoclastic differentiation factor (ODF). RANKL is widely ex-
pressed in bone and lymphoid tissues and especially on the surface
of osteoblasts stimulated by osteotropic factors such as PTH,
1,25(OH)
2
D
3
or TNF-. The extracellular domain of RANKL
binds to its specific receptor RANK, which is expressed on the
plasma membrane of monocyte-macrophage lineage osteoclast
precursor cells, as well as in mature osteoclasts and dendritic cells.
This binding induces various intracellular signaling cascades in-
cluding nuclear factor (NF)-kappaB, c-Jun N-terminus kinase
(JNK) and p38 mitogen-activated protein tyrosine kinase (MAPK)
activation, and thus promotes differentiation, activation and sur-
vival of osteoclasts [70].
The other important component in this homeostatic system is
osteoprotegerin (OPG), a TNF family member that acts like a solu-
ble decoy receptor of RANKL: OPG specifically binds to RANKL
and inhibits its activity by preventing its binding to RANK. In pa-
tients with MAH, abnormal activation of RANKL is mediated ei-
420 Current Medicinal Chemistry, 2008 Vol. 15, No. 4 Lumachi et al.
ther by circulating PTHrP in the absence of tumor bone involve-
ment or by a complex network of cytokines secreted locally by
metastatic cells invading the bone, as well as by surrounding nor-
mal cells such as IL-1 and IL-6, TNF- and TGF- [71]. The obser-
vation that, in vitro, OPG inhibits differentiation of osteoclasts,
blocks bone resorption by mature osteoclasts , and promotes apop-
tosis of osteoclasts, suggested the use of recombinant OPG in vivo
in murine models of tumor-induced hypercalcemia, showing that
the administration of OPG can both prevent and reverse MAH,
leading to a rapid normalization of blood calcium levels [72-75]. A
recent study has compared the antiresorptive activity of recombi-
nant OPG and bisphosphonates in two murine models of PTHrP-
dependent MAH. OPG induces a more rapid effect on bone resorp-
tion, probably due to the unique mechanism of action of RANKL
inhibitors. They do not bind to the bone matrix substrate, cause a
nearly immediate arrest of osteoclast activity, and shortened sur-
vival. Moreover, OPG treatment also resulted in a greater reduction
of markers of bone resorption associated with a sustained reversal
of hypercalcemia [76]. Preliminary data from small studies involv-
ing women with osteoporosis have shown the effectiveness and
safety of subcutaneous injections of OPG in rapidly reducing bone
turnover for a sustained period [77]. A recombinant soluble form of
human RANK, representing the entire extracellular domain ex-
pressed as a fusion protein with the constant fragment of human
immunoglobulin G (IgG Fc), has been shown to act as a functional
antagonist of RANK-mediated signaling in vitro [78]. The use of a
murine RANK-human immunoglobulin fusion protein (muRANK
Fc) was tested in vivo in a murine model of MAH, demonstrating its
potent antiresorptive effect [79].
Another agent able to disrupt RANKL-RANK signaling path-
way is the fully human monoclonal antibody against RANKL,
named denosumab (or AMG 162), which blocks RANKL-RANK
interaction, mimicking the physiologic effects of OPG. The first
clinical study with denosumab, administered by subcutaneous injec-
tion and performed in postmenopausal osteoporotic women,
showed potent antiresorptive effect, with a dose-dependent, rapid
and sustained decrease of bone turnover, and effect which was con-
firmed in subsequent trials [80, 81]. Another study demonstrated
the effectiveness and safety profile of denosumab in inducing an
early and sustained decrease of bone resorption in patients with
multiple myeloma or breast cancer metastatized to bone [82]. Cur-
rently, larger clinical trials investigating the effect of this agent for
the treatment of cancer-induced bone disease are underway, but the
role in the acute management of MAH has not already been docu-
mented [83]. The observation of the relapse of hypercalcemia in
mice with MAH treated with antiresorptive agents, despite the evi-
dence of persistent suppression of bone resorption, demonstrated
that the inhibition of RANKL system does not affect another criti-
cal component of hypercalcemia caused by PTHrP secretion, that is
the inhibition of calcium excretion from the kidney [76]. Indeed,
high levels of circulating PTHrP (not influenced by antiresorptive
agents) may persistently enhance renal tubular calcium reabsorp-
tion, and this seems to be one of the major causes of the emergence
of bisphosphonates- and calcitonine-refractory HHM [84]. In dif-
ferent experimental models of PTHrP dependent MAH, it was
shown that administration of either monoclonal or polyclonal anti-
bodies against human PTHrP may lower serum calcium levels and
prolong survival [85, 86]. Furthermore, a humanized antibody
against human PTHrP was generated for the clinical application and
tested in animal models of MAH, demonstrating its ability to fully
neutralize PTHrP functions, with a complete normalization of blood
ionized calcium level through an improvement of bone metabolism
and calcium renal excretion [84, 87]. The blockage of PTHrP func-
tions by a neutralizing antibody would benefit especially subjects
developing bisphosphonate-refractory MAH [84]. The treatment
with ibandronate has not been demonstrated to be able to modify
levels of OPG even in patients with decrease of calcium as a proof
of non cross-resistant mechanism of action [88].
In spite of the scientific evidence of the central role of RANKL
system in bone pathology, clinical application of anti-RANKL ther-
apy has just begun and there is a need of further clinical studies to
uncover all its possible advantages in patients with acute MAH.
CONCLUSIONS
MAH and primary HPT account for over 90% of all causes of
hypercalcemia. Thus, in all patients with malignancy primary HPT
should be considered in the differential diagnosis, to ensure suc-
cessful treatment. In patients with MAH the first step of therapy is
usually to restore renal function which is often impaired due to
dehydration. Since enhanced bone resorption represents the main
cause of MAH, the second step is bisphosphonates administration.
Pamidronate, zoledronate and ibandronate are at present the main-
stay of treatment. Non-bisphosphonates drugs (i.e. calcitonin, gal-
lium nitrate, mythramicin) have limited activity and several side
effects. Anti-RANKL therapy (i.e. denosumab) and antibodies
against PTHrP are promising therapies, but their clinical use should
be further explored to more clearly document the effect.
ACKNOWLEDGEMENTS
A special thank you to Mrs Francesca Bissolotti for help in
writing the manuscript and for reviewing the English.
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Received: September 30, 2007 Revised: December 01, 2007 Accepted: December 02, 2007


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