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Hypercalcemia of malignancy

Last reviewed: 4 Apr 2025
Last updated: 18 Jul 2023

Summary

Definition

History and exam

Key diagnostic factors

  • history of malignancy
Full details

Other diagnostic factors

  • normal physical exam
  • poor skin turgor and/or dry mucous membranes
  • confusion
  • fatigue
  • constipation
  • loss of appetite
  • nausea
  • polyuria
  • polydipsia
  • bone pain
  • use of hypercalcemia-inducing medication
  • stupor
  • coma
Full details

Risk factors

  • nonmetastatic malignancy
  • metastatic skeletal involvement
  • lymphoma
Full details

Diagnostic tests

1st tests to order

  • total serum calcium
  • serum ionized calcium
  • serum albumin
  • comprehensive metabolic panel
  • resting ECG
  • serum intact parathyroid hormone
  • serum parathyroid hormone-related peptide
  • serum phosphorus
  • serum calcitriol (1,25-dihydroxyvitamin D)
  • serum 25-hydroxyvitamin D
Full details

Tests to consider

  • skeletal survey
  • chest x-ray
Full details

Treatment algorithm

ACUTE

mild hypercalcemia or asymptomatic moderate hypercalcemia

symptomatic moderate or severe hypercalcemia: without advanced kidney disease

symptomatic moderate or severe hypercalcemia: with advanced kidney disease

Contributors

Authors

Assistant Professor of Medicine

Division of Geriatric Medicine

Department of Medicine

University of California, Los Angeles

Los Angeles

CA

Disclosures

AS declares that he has no competing interests.

Clinical Professor of Medicine

Division of Endocrinology

Department of Medicine

University of California, Los Angeles

Los Angeles

CA

Disclosures

DM declares that she has no competing interests.

Peer reviewers

Professor

Endocrinology Fellowship Training Program

Department of Clinical Diabetes, Endocrinology, and Metabolism

City of Hope National Medical Center

Duarte

CA

Disclosures

KCC declares that he has no competing interests.

Consultant and Senior Lecturer

Endocrine Unit

Newcastle University and Royal Victoria Infirmary

Newcastle-upon-Tyne

UK

Disclosures

RQ has been reimbursed by Amgen, the manufacturer of Cinacalcet, for attending a conference and for giving an educational seminar (total under £1,200 over past 3 years).

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Cancer Institute NSW. Hypercalcaemia of malignancy (HCM). Jul 2019 [internet publication].Full text

Guise TA, Wysolmerski JJ. Cancer-associated hypercalcemia. N Engl J Med. 2022 Apr 14;386(15):1443-51. Abstract

Horwitz MJ. Chapter 84: Non-parathyroid hypercalcemia. In: Bilezikian JP, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. 9th ed. Washington, DC: American Society of Bone and Mineral Research; 2018:639-45.

El-Hajj Fuleihan G, Clines GA, Hu MI, et al. Treatment of hypercalcemia of malignancy in adults: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):507-28.Full text  Abstract

Stewart AF. Clinical practice. Hypercalcemia associated with cancer. N Engl J Med. 2005 Jan 27;352(4):373-9. Abstract

Alberta Provincial Tumour Council. Oncologic emergencies: a guide for family physicians. Sep 2014 [internet publication].Full text

Society for Endocrinology. Emergency management of acute hypocalcaemia in adult patients. Sep 2016 [internet publication].Full text

Horwitz MJ, Hodak SP, Steward AF. Non-parathyroid hypercalcemia. In: Rosen CJ, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. 8th ed. Washington, DC: American Society of Bone and Mineral Research; 2013:562-71.

Major P, Lortholary A, Hon J, et al. Zoledronic acid is superior to pamidronate in the treatment of hypercalcemia of malignancy: a pooled analysis of two randomized, controlled clinical trials. J Clin Oncol. 2001 Jan 15;19(2):558-67. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Hypercalcemia of malignancy images
  • Differentials

    • Primary hyperparathyroidism
    • Hyperthyroidism
    • Adrenal insufficiency
    More Differentials
  • Guidelines

    • Cancer guidelines: symptom management. Oncologic emergencies
    • Treatment of hypercalcemia of malignancy in adults: an Endocrine Society clinical practice guideline
    More Guidelines
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