Pi Is 0085253815338837

Kidney International, Vol. 31(1987), pp.
142—155
NEPHROLOGY FORUM
The hypercalcemia of malignancy

Principal discussant: GREGORY R. MUNDY
The University of Texas Health Science Center, San Antonio, Texas
mg/dl. Plasma PTH (C-terminal) was 50 zEq/ml (normal, 20—120

Editors Eq/ml).
He was treated with salmon calcitonin, 200 MRC units intramuscu-
JORDAN J. COHEN larly each 12 hours, and hydrocortisone, 100 mg intravenously each 6
JOHN T. HARRINGTON hours, and vigorous infusion of normal saline. After 4 days, calcitonin
JEROME P. KASSIRER was withdrawn and he was given oral corticosteroids. The BUN
NICOLAOS E. MADIAS gradually fell to 20 mgldl. Biopsy of the right supraclavicular mass
revealed lymphoid tissue extensively infiltrated with squamous cell
carcinoma. Although the serum calcium level was controlled by medical
Managing Editor therapy, the advancing malignancy caused a progressive deterioration.
CHERYL J. ZUSMAN Chemotherapy was not considered advisable, and he died one month
after the second admission.
Autopsy disclosed squamous cell carcinoma of the left upper lobe of
University of Chicago Pritzker School of Medicine the lung with widespread metastases in the liver, right lung, lymph
and nodes, brain, and bone marrow. There was no evidence of bone
metastases. The parathyroid glands were normal. Metastatic tumor
Tufts University School of Medicine tissue obtained from the right supraclavicular lymph nodes was probed
with a cDNA probe for parathyroid hormone and a cDNA probe for
transforming growth factor (TGF)a using the Northern technique.
Case presentations Parathyroid hormone was not expressed, but TGFa mRNA was ex-
pressed excessively.
Patient I. A 54-year-old black man was admitted to the Audie Patient 2. A 43-year-old factory worker came to the Royal Hobart
Murphy Memorial Veterans Hospital in San Antonio 3 years ago with a Hospital, Hobart, Tasmania, with severe low-back pain of 2 months
history of pain in the left clavicular region and weakness and pain in the
duration, confusion, and dehydration. At the time of admission, he was
left arm that had been present for approximately one month. He had thin, lethargic, and disoriented; the pulse was 120 beats/mm and the
lost 40 pounds over the previous year and for 6 months had had a cough blood pressure was 90/60 mm Hg. The serum calcium was 15 mgldl;
productive of sputum, which recently had become blood streaked. He serum albumin, 3.9 g/dl; blood urea, 80 mg/dl; and serum creatinine, 4
mg/dl. A radiologic survey showed widespread osteolytic lesions in the
had smoked one pack of cigarettes per day for 40 years. Physical skull and long bones, and osteopenia of the vetebral bodies with
examination revealed a thin man weighing only 80 pounds with a hard,
collapse of T7 and T8. A bone marrow examination revealed increased
nontender mass in the left supraclavicular region. He had decreased cellularity with marked rouleaux formation and increased background
sensation over the lateral aspect of the left arm, and Homer's syndrome staining. Myeloma cells comprised 80% of all nucleated marrow ele-
was present. No abnormal motor findings were present. Chest x-ray ments and included binuclear forms and syncytia. Plasma protein
revealed a mass in the left upper lobe of the lung consistent with a electrophoresis revealed an abnormal band in the gamma region, and
Pancoast tumor. The lung mass measured 4 x 2 cm. Sputum cytology
was consistent with squamous cell carcinoma. Bronchoscopy showed plasma protein immunoelectrophoresis showed an IgG monoclonal
no evidence of an endobronchial lesion, although the bronchoscopy protein. Immunoglobulin assays revealed an IgA of 130 mg/dl (normal,
washings were positive for squamous cell carcinoma. During this 167—410 mgldl); IgG, 3000 mg/dl (normal, 870—1520 mg/dl); and 1gM, 20
admission the serum calcium was 10.5 mg/dl and the serum albumin 3.6 mg/dl (normal 50-110 mg/dl). Bence Jones proteinuria was present. The
patient was given 6 liters of normal saline during the first 24 hours after
g/dl. A bone scan, CT scans of the abdomen and head, and an ab- admission and was treated with corticosteroid therapy (100 mg
dominal sonogram revealed no evidence of metastatic disease. Local hydrocortisone intravenously every 6 hours), and the serum calcium fell
radiation therapy produced relief of the bone pain. The patient received
5400 rads to the left upper lobe and 4000 rads to the mediastinum and to 10.5 mgldl over the ensuing 3 days. His lethargy and confusion
supraclavicular area. improved markedly, and he was able to give a clear history of disabling
The patient was discharged but was readmitted to the hospital 2 back pain, which had been progressive in the weeks prior to admission.
months later with marked confusion. His mental status had deteriorated Symptomatic improvement followed treatment with cyclophospha-
rapidly over the week prior to admission. The findings were the same as mide for myeloma, with relief of the bone pain. He was not able to
on the first admission, except that now he was dehydrated, the blood return to work but was able to walk with the aid of crutches and to
pressure was 80/40 mm Hg, and a new mass was present in the right return home. During the remission, a small maintenance dose of
supraclavicular region. The serum calcium was 16.0 mg/dl; albumin, 2.9 corticosteroid (prednisone, 10 mg daily) was required to keep the serum
g/dl; sodium, 130 mEq/liter; chloride, 100 mEq/liter; bicarbonate, 26 calcium within the normal range. When the bone pain recurred 5
mEq/liter; potassium, 4.2 mEq/liter; BUN, 38 mg/dl; and creatinine, 2.1 months later, cyclophosphamide was discontinued; melphalan and local
radiation therapy to his back again relieved local symptoms. The serum
calcium remained in or near the normal range and corticosteroid
therapy was continued. He was readmitted one year after the initial
Presentation of the Forum is made possible by grants from Merck Sharp admission with fever and hypotension. Blood cultures revealed gram-
& Dohme, Pfizer Laboratories, and Sandoz, Incorporated. negative bacteria. The serum calcium did not exceed 11 mg/dl. Despite
© 1987 by the International Society of Nephrology antibiotic therapy he died 48 hours after admission.
142
The hypercalcemia of malignancy 143
Discussion 1 g/day
DR. GREGORY R. MUNDY (Head, Division of Endocrinology

and Metabolism, and Professor of Medicine, The University of
Texas Health Science Center, San Antonio, Texas): These two
cases illustrate the wide range of circumstances under which
patients with malignancy develop hypercalcemia. The first
patient had hypercalcemia in association with a solid tumor
(squamous cell carcinoma of the lung) and without evidence of
bone metastasis. This syndrome is known as humoral hypercal-
cemia of malignancy, and presumably is due to circulating
tumor products, which increase both bone resorption and renal
tubular calcium reabsorption and lead to an increase in extra-
cellular fluid calcium. Tumor tissue from this patient was
probed for evidence of both PTH mRNA expression, and TGFc
mRNA expression (by Dr. R. Derynck, of Genentech Inc.,
South San Francisco). There was no evidence of PTH biosyn-
thesis, but TGFa was clearly synthesized by this tumor and is
likely to be responsible, at least in part, for the hypercalcemia.
(This patient comprised one of the cases reported by Simpson et
al [11.) The second patient, who made a lasting impression on
me when I was a house officer, had extensive lytic bone de-
struction in association with myeloma, and in addition had
hypercalcemia with fixed impairment of renal function. In this Fig. 1. Estimates of calcium balance and amounts of calcium exchange
case, the hypercalcemia presumably was due to localized bone between bone, gut, kidney, and soft tissue and the extracellular fluid in
destruction mediated by locally active myeloma cell products, a normal adult in zero calcium balance.
in association with decreased renal calcium clearance due to
impaired glomerular filtration. The prognosis in both patients
was poor. The hypercalcemia was controlled satisfactorily with ologic mechanisms that have been linked with the presence of
medical therapy, but both patients expired from advancing hypercalcemia in patients with malignant disease.
malignancy within twelve months. These 2 patients illustrate
that the pathophysiologic mechanisms responsible for hypercal- Normal calcium homeostasis
cemia in patients with malignancy are heterogeneous from Extracellular fluid calcium is regulated primarily by the
tumor type to tumor type [21. As will become apparent during effects of three systemic hormones, each of which in turn is
the following discussion, many individual tumors probably controlled (either directly or indirectly) by serum ionized cal-
produce several products that work in concert to disrupt cium, thus yielding three negative feedback loops. These three
calcium homeostasis. This should not be surprising, because hormones are parathyroid hormone (PTH); 1,25 dihydroxyvi-
extracellular fluid calcium is normally under such tight regula- tamin D (l,25D); and calcitonin. The relative importance of
tion. Any disease process that causes a disturbance in this each of these hormonal systems on calcium homeostasis is not
superb homeostatic mechanism must be not only powerful, but fully clear, nor is it certain that there are not additional
also is likely to be complex. As studies on the pathophysiology important mechanisms, possibly mediated at the tissue level of
of hypercalcemia and malignancy proceed, knowledge probably the target organs. However, at least as far as chronic control of
will accumulate not only on how individual tumor products serum calcium is concerned, PTH and l,25D are clearly more
affect target organs, but also on how these multiple effects important than is calcitonin, which may have only acute or
interact to cause an increase in serum calcium. transient effects. I say this because persistent alterations in
Hypercalcemia, a relatively common clinical problem, has calcium homeostasis do not occur either with absence of the
become even more frequently recognized as autoanalyzer mea-
thyroid gland or with tumors of the calcitonin-secreting cells
surements of serum calcium have become routine on all serum (medullary thyroid carcinoma).
The maintenance of serum calcium depends on the transport
samples drawn for electrolyte determinations. After the patient of calcium across three organs: the gut, kidney, and bone (Fig.
is recognized as having hypercalcemia, a number of diagnostic 1). Several points about calcium transport across these organs
possibilities that might not have been considered previously are and their relationship with the extracellular fluid should be
raised. Primary hyperparathyroidism is the most common cause emphasized, because they are important in the hypercalcemia
in the ambulant population, and patients with this disorder are of malignancy. Bone is an enormous reservoir for calcium. Of
often asymptomatic [3, 4]. Current estimates are that primary the total calcium in the body, 99% is present in bone. In the
hyperparathyroidism may have the astonishing annual inci- normal adult before middle life, bone resorption and bone
dence rate of 250 new patients per million population per year formation are in balance, but the amount of calcium exchanged
[3, 4}. In hospitalized patients, such as the 2 presented here, per day with the extracellular fluid is relatively small. Bone
malignant disease is the commonest cause of hypercalcemia. In resorption and bone formation lead to a daily exchange of
the following discussion I will review the multiple pathophysi- approximately 500 mg of calcium with the extracellular fluid.
144 Nephrology Forum
This amount is less than one-millionth of the total skeletal bone resorption. Whether net bone resorption occurs in any
calcium. Although bone is a potential major source of calcium, individual patient often is difficult to know. The changes in
whether acute control of serum calcium is regulated by the calcium transport across the gut, kidney, and bone are not
balance between resorption and formation is still unknown. caused by PTH alone, but rather by the combined effects of
In contrast, the kidney filters large amounts of calcium, only PTH and 1,25 dihydroxyvitamin D [6], which is synthesized in
to reclaim the great majority by tubular reabsorption: approxi- the proximal tubules of the kidney in response to PTH.
mately 10 g cross the glomerulus each day, 98% of which is Hypercalcemia rarely occurs in secondary hyperparathyroid-
reabsorbed by the renal tubules. Approximately 65% is reab- ism in spite of PTH concentrations far above the normal range,
sorbed in the proximal tubule, 20% to 25% in the ascending limb because 1,25 dihydroxyvitamin D concentrations are low.
of Henle's ioop, and approximately 10% in the distal tubule. In Moreover, the effects of PTH on both bone and kidney are
the normal individual, fine regulation of calcium reabsorption almost certainly increased by, and in fact may be dependent on,
occurs at the level of the distal tubule, primarily under the 1,25 dihydroxyvitamin D. There is evidence that 1,25 dihydroxy-
influence of parathyroid hormone. In the proximal tubule, vitamin D enhances the effects of PTH on calcium reabsorption
calcium reabsorption probably is not influenced by PTH, but in the distal tubule [6], and that l,25D works in concert with
rather is linked to sodium and volume reabsorption. PTH on bone [71. Thus hypercalcemia in primary hyper-
In the gastrointestinal tract, dietary calcium is absorbed parathyroidism results not from effects of PTH alone, but rather
under the primary influence of 1,25 dihydroxyvitamin D (and from the combined effects of PTH and 1,25 dihydroxyvitamin D
indirectly by PTH, which stimulates production of 1,25 dihy- on kidney and bone and from the effect of 1,25 dihydroxyvita-
droxyvitamin D by the kidney). Little is known about the mm D on the gut.
regulation of calcium excretion into the gut lumen via intestinal
juices. In normal individuals in calcium balance, net absorption Pathophysiology of hypercalcemia in malignant disease
from the gut is equivalent to the amount of calcium excreted in No type of non-parathyroid malignancy yet described mimics
the urine, and usually is in the range of 150 to 250 mg/day. exactly the changes in calcium transport that occur in primary
Calcium exchange also occurs between the extracellular fluid hyperparathyroidism. In malignant disease, a number of dil-
and the soft tissues. This exchange is of course relatively minor ferent but distinct patterns exist—and possibly more—that have
compared with the fluxes that occur across kidney, bone, and yet to be fully elucidated. These patterns are represented
gut. Whether the exchange between soft tissues and the extra- diagrammatically in Figure 2. I will discuss three examples in
cellular fluid is hormonally regulated is not known. which the pathophysiology is different: solid tumors with
Several aspects of this complex system are important to the hypercalcemia, multiple myeloma, and T-cell lymphomas.
pathophysiology of hypercalcemia in malignant disease. (I) The Solid tumors and hypercalcemia. The two commonest causes
system is highly integrated (even appearing redundant at first of hypercalcemia of malignancy are lung cancer and breast
glance) and contains many checks and balances against the cancer [8]. The clinical circumstances under which hypercalce-
occurrence of hypercalcemia or hypocalcemia. (2) The kidney mia occurs in these two conditions are often very different,
has a considerable, although finite, capacity to protect against however. Hypercalcemia can occur early or late in lung cancer,
an increase in the entry of calcium into the extracellular fluid and it may or may not be associated with bone metastases. In
sufficient to cause hypercalcemia. The kidney can increase contrast, hypercalcemia in breast cancer usually occurs only
calcium excretion by about fivefold to maintain normal extra- late in the disease and in patients who have extensive bone and
cellular fluid calcium. Maximal urinary calcium excretion rates other metastases. The general pathophysiologic disturbance in
usually are not more than 600 mg/day; in many hypercalcemic calcium transport mechanisms may be similar in both types of
patients, despite a lack of PTH in the circulation, distal renal tumors, but there are probably differences in the humoral
tubular calcium reabsorption almost certainly is occurring. (3) mechanisms causing these disturbances.
Bone, an enormous potential reservoir of calcium, could pro- In lung cancer and related solid tumors associated with
vide an important source of calcium together with calcium hypercalcemia (neoplasms of the kidney, pancreas, ovary, and
absorbed from the gut. The increased entry of calcium into the squamous cell tumors of the head and neck), hypercalcemia is
extracellular fluid has been termed "through-put" by Nordin, associated with increased bone resorption, probably decreased
Peacock, and coworkers [5]. In the presence of a three- to bone formation, and increased renal tubular calcium reabsorp-
fivefold increase in bone resorption rate, "through-put" in- tion (for review, see Refs. 2 and 9). Gut absorption of calcium
creases, and the kidney's capacity to excrete calcium is over- is decreased in those cases in which it has been measured. The
whelmed. role of humoral and nonhumoral mechanisms in these distur-
bances is fiercely debated. Several different tumor factors are
Pathophysiology of hypercalcemia in primary involved, just as two different humoral factors are involved in
hyperparathyroidism the pathophysiology of hypercalcemia in primary hyperpara-
thyroidism. In comparison with normal individuals and patients
Primary hyperparathyroidism is the commonest cause of with primary hyperparathyroidism, a marked increase in bone
hypercalcemia. Most cases are due to a benign, single parathy- resorption must exist in these cancer patients to provide suffi-
roid gland adenoma that secretes excessive PTH. The serum cient input of calcium into the extracellular fluid (in the pres-
calcium is elevated because of both an increase in calcium ence of the decreased gut absorption of calcium) to cause an
absorption from the gut and increased renal tubular calcium increase in serum calcium. The urinary calcium excretion is in
reabsorption. The role of bone is unclear. Bone turnover is the same range as that in patients with primary hyperpara-
clearly stimulated, with increases both in bone formation and thyroidism, indicating that renal tubular calcium reabsorption is
in which the secretion of the tumors is constrained by feedback

mechanisms. A good example is Cushing's syndrome due to
—SC +* a7
Lung Cancer small ACTH-secreting pituitary tumors. These pituitary tumors
can respond to pharmacologic concentrations of cortisol (the
basis of the high-dose dexamethasone suppression test), but
when the adrenals are removed and only maintenance replace-
£
cAMP ment doses of cortisone are given (less than the amounts of
cortisol produced by the abnormal glands prior to removal), the
pituitary tumor can grow actively and cause Nelson's syn-
drome.
Myeloma. Myeloma almost always is accompanied by in-
creased osteoclastic bone resorption and often by hypercalce-
mia [11]. The hypercalcemia is associated with increased bone
resorption, decreased glomerular filtration, and decreased ab-
sorption of calcium from the gastrointestinal tract. In the
skeleton, rates of bone formation are usually decreased, and the
x-rays show discrete punched-out osteolytic lesions or gener-
Lymphoma Breast Cancer
alized osteopenia with little or no evidence of new bone
ci formation. Reduced bone formation is confirmed by bone
scans, which indicate little uptake of the labeled bisphosphon-
ate by serum alkaline phosphatase mechanisms, a reliable
measure of mature osteoblast activity. Impaired glomerular
filtration could be the consequence of a combination of disor-
ders including Bence Jones proteinuria, uric acid nephropathy,
pyelonephritis, and occasionally amyloidosis. Renal tubular
calcium reabsorption is not increased unless a reversible ele-
Fig. 2. Patterns of abnormalities in calcium transport in patients with
ment of decreased glomerular filtration is superimposed due to
different types of hypercalcemia of malignancy. The upper left panel
represents the abnormalities in myeloma, where increased bone resorp- decreased renal blood flow.
tion, decreased bone formation, decreased calcium absorption from the T-cell lymphomas. Hypercalcemia occurs much less com-
gut, and impaired glomerular filtration are associated with hypercal- monly in other forms of hematologic malignancy than it does in
cemia. The upper right panel indicates the situation in solid tumors, myeloma. In one special type, however, it is present in almost
such as lung cancer, which may or may not be associated with
metastases. In this case there is increased bone resorption, decreased all the patients. This disorder is the human T-cell lymphotropic
bone formation, increased renal tubular calcium reabsorption and virus, type-i adult T-cell lymphoma, which is particularly
decreased calcium absorption from the gut. These patients frequently common in the southeastern United States, the Caribbean, and
have increased nephrogenous cyclic AMP production. The lower right Japan. Lymphoid cells carrying this virus produce most of the
panel shows the situation in breast cancer, which is similar to that in
lung cancer except that the patients almost always have bone metasta- known lymphokines [12], and increased bone resorption is
ses and usually do not have increased nephrogenous cyclic AMP. The likely due at least in part to one or more of the cytokines that
lower left panel shows the unusual group of patients with various resorb bone. Moreover, we have found macromolecular bone-
lymphomas and malignancy who may have increased calcium absorp- resorbing activity in cell culture supernatants [13]. An addi-
tion from the gut because of an increased 1 ,25D concentration intional mechanism also might be operative in this situation.
association with increased bone resorption.
Some of these patients, as well as some others with lympho-
proliferative malignancies and hypercalcemia, have increased
serum concentrations of 1,25 dihydroxyvitamin D, and in-
increased and that the relative increase in bone resorption over creased calcium absorption from the gut [14]. These findings
bone formation must be considerable to account for the contrast with those in other patients with hypercalcemia of
hypercalcemia, given the decreased calcium absorption from malignancy, in whom calcium absorption from the gut and
the gut in this condition. In comparison, patients with primary serum 1 ,25D concentrations are almost invariably decreased.
hyperparathyroidism have similar increases in the serum cal- We have examined lymphoid cells infected with this virus and
cium, but calcium absorption from the gut is increased rather found that they have the capacity to convert 25 hydroxyvitamin
than decreased, as in most patients with hypercalcemia of D to 1,25 dihydroxyvitamin D [15].
malignancy. In malignancy, hypercalcemia usually is steadily
progressive, unlike primary hyperparathyroidism, in which the Increased bone resorption in hypercalcemia of malignancy
level of serum calcium can remain constant for many years. Bone resorption is increased in patients with hypercalcemia
Possibly in primary hyperparathyroidism there is still some associated with malignancy. This phenomenon is well docu-
form of negative feedback, by extracellular fluid calcium on mented in histomorphometric studies of bone surfaces, which
parathyroid hormone synthesis and secretion, as well as possi- show evidence of increases in osteoclast activity, particularly
bly on the number of PTH-secreting cells, which establishes a on trabecular surfaces [16, 17]. The morphologic changes in
new "set-point" for the relationship between serum calcium bone are different from those of primary hyperparathyroidism,
and PTH secretion different from the normal [10]. This might be however. In primary hyperparathyroidism, cortical resorp-
similar to the situation in many patients with pituitary tumors, tion—and particularly subperiosteal resorption—is prominent,
whereas this form of osteoclastic bone resorption rarely if ever Effects of TGFa and PTH on Bone in vitro
is found in malignancy-associated hypercalcemia. Moreover, in ,TGFa 0PTH
malignancy, rates of bone formation are decreased [161. This 3.0 60
finding again contrasts with that in primary hyperparathyroid- a,
ism, in which bone turnover is increased and rates of bone 2.0 Ca
40
formation are increased. A word of caution is still necessary to -I S
avoid overinterpreting the information on rates of bone forma- U- 1.0 20
tion in hypercalcemia of malignancy. Studies on bone formation T 60
--0
have not been controlled by examination of nonhypercalcemic
cancer patients; it is possible that the decreased rates of
40 //
20
formation observed are due to other factors such as poor
nutrition, wasting, or immobilization, frequent sequelae in
io io b_b I io-
C-)
patients with cancer.

Other clinical evidence indicates that rates of bone resorption
10—10 I bo_8
io- io
Concentration (M)
are increased in patients with the hypercalcemia of malignancy.
Fig. 3. Effects of recombinant human TGFa and parathyroid hormone
Urinary hydroxyproline is increased, x-rays frequently show on parameters of bone resorption and bone formation in vitro. Recom-
signs of destructive bone lesions (particularly in patients with binant human TGFa was obtained from Dr. Rik Derynck from
breast cancer and with myeloma), and hypercalcemia is almost Genentech, Incorporated [30]. PTH was bovine PTH (1—84). FRLB
always alleviated by drugs that specifically inhibit osteoclastic represents fetal rat long bones, in which bone resorption is assessed by
bone resorption, such as plicamycin (mithramycin) and the the release of previously incorporated 45Ca over 72 hours of organ
culture. NMC represents neonatal mouse calvaria that also have been
newer bisphosphonates [18]. prelabeled with 45Ca and cultured in the presence of the bone-resorbing
The notion that increased bone resorption plays a major role factor for periods of 72 hours. Alkp'ase is alkaline phosphatase content
in the pathophysiology of the hypercalcemia associated with in cells with osteoblast characteristics assessed as the percentage
malignancy is confirmed by the demonstration from many decrease in response to TGFa and PTH. Coil synth is the percentage of
studies of in-vitro bone-resorbing activity in tumor extracts of inhibition of collagen synthesis measured as collagenase-digestible
protein in fetal rat calvarial organ cultures.
culture supernatants of tumor cell lines derived from patients or
animal models of the hypercalcemia of malignancy. The major
area of controversy in this field is the nature of the humoral
mediator or mediators produced by these tumors, and the anism, possibly directed by an oncogene [23]. Epidermal
relative importance of bone resorption compared with other growth factor (EGF) receptor binds TGFa, and the peptide
mechanisms, such as increased renal tubular calcium reabsorp- probably mediates all its effects through this receptor [26, 27].
tion, in the pathogenesis of the hypercalcemia. Six factors have TGFa causes all the known biologic effects of EGF, and
been proposed as potential mediators of increased bone resorp- evidence indicates that its binding site on the EGF receptor is
tion associated with hypercalcemia. These are the transforming similar or even identical to that of EGF, in spite of an amino
growth factors, the parathyroid hormone-like factors, the pros- acid homology with EGF that is not more than 40%; however,
taglandins, the leukocyte cytokines, 1,25 dihydroxyvitamin D, both molecules contain a similar conformation and three
disulfide bonds. The close overlap of the biologic effects of
and colony-stimulating factors. It appears likely that there also
will be other factors, not yet fully identified, that will be TGFa with those of EGF was the rationale for our investigation
responsible for hypercalcemia in some tumor types [19]. of the role of TGFa in the bone destruction associated with
Transforming growth factors. The tumor-derived transform- malignancy. Both the synthetic and recombinant forms have
ing growth factors, polypeptide stimulators of cell replication, powerful effects on bone cell metabolism [27—30]. They clearly
are produced by most, if not all, tumors. Two major classes stimulate osteoclastic bone resorption in both neonatal mouse
have been identified, TGFa and TGF/3. Although interest in calvaria and fetal rat long bones (Fig. 3). The effects on neonatal
TGF/3 and its effects on bone is intense, currently more is mouse calvaria are mediated by prostaglandins and can be
known about the effects of TGFa on bone cell function. Many inhibited by indomethacin, although osteoclastic bone resorp-
tumors produce TGFa, including the solid tumors commonly tion in fetal rat long bones is not affected by indomethacin [28,
associated with hypercalcemia such as squamous cell carci- 301. Identical results are found in both of these systems with
noma of the lung, head and neck, kidney, and breast. Such EGF. However, in our hands, osteoclastic bone resorption
polypeptides obtained from the rat and human have been occurs at concentrations at least one order of magnitude lower
purified [20, 211 and that from the rat has been synthesized than those of EGF [301. The effects of TGFa also are important
chemically [22]. The rat and the human genes have been cloned in in-vitro systems for bone formation. It is a powerful inhibitor
[23, 24], and the human material has been engineered for of collagenase-digestible protein synthesis in fetal rat calvaria
expression in E. coli [24]. A 5000 dalton peptide, TGFa has a and inhibits the alkaline phosphatase content of rat osteosarco-
sequence of 50 amino acids. However, larger forms also are ma cells with the osteoblast phenotype [30]. In fetal rat calvaria,
found in tumor cell culture supernatants and probably represent TGFa stimulates DNA synthesis [30]. Its actions on osteoclas-
unprocessed forms of the molecule [25]. The TGFa precursor tic bone resorption may be mediated by effects on osteoclast
has a relatively unique structure without a leader sequence and progenitors; we found in our long-term marrow culture system
with an amino acid configuration, suggesting that it is a that TGFa stimulates increased formation of cells with
transmembrane protein. Release of the precursor from the osteoclast characteristics by increasing proliferation of mono-
membrane of the cell might involve a novel proteolytic mech- nuclear cells [31]. The stimulatory action in this system occurs
in concentrations as low as 0.01 ng/ml, the lowest concentration A

of TGFa yet known to produce a biologic effect in any system. 2.0
Strong evidence suggests that TGFa plays an important role
in the increased bone resorption associated with some tumors.
1.8
The most thoroughly studied model has been the rat Leydig cell a)
Ce
tumor, which occurs in 50% of aged Fischer rats and can be a)
1)
carried in culture or transplanted subcutaneously [32]. The rats 1.6
become rapidly hypercalcemic over 3 weeks and have most of
the characteristics of the humoral hypercalcemia of malignancy 0
0
seen in patients with solid tumors. Leydig tumors produce both Ce 1.4
bone-resorbing activity and TGFa activity, which co-elutes 0
C
from gel filtration columns [33]. The Leydig tumor expresses 0
C)
TGFa mRNA excessively. In fact, it expresses TGFa in 1.2
comparable amounts to the FeSV tumor from which TGFa was Ce
Ce
I
purified and the gene cloned. Moreover, the bone-resorbing I-
1.0
activity present in Leydig tumor cell culture supernatants can
be blocked by neutralizing antibodies to the EGF receptor [34,
35]. These antibodies, supplied by Dr. Graham Carpenter at 0.8
Vanderbilt University, are of two types, one that binds to the TCM 1CM TCM 1CM PTH PTH EGF EGF
EGF binding site and blocks the biologic effects of EGF and + + + + +
1/300 1/1000 1/3000 1/300 1/300
TGFa, and another that is separate from the EGF binding site
Dilution of Ab 451
and does not block the biologic effects of EGF or TGFa. We
have found that the antibodies that bind to the EGF binding site
inhibit the bone-resorbing activity produced by the Leydig B
tumor, but that the antibodies that do not block the effects of 2.0
TGFa have no effect on the bone-resorbing activity (Fig. 4A,
4B). We also have obtained similar results in several other a) 1.8
tumors associated with hypercalcemia. A human squamous cell a)
carcinoma of the lung, which has been well characterized and Ce
Ce
described by Kukreja, Abramson, and associates at the Univer- C) 1.6
sity of Chicago, expresses TGFa excessively, and the bone- 0
resorbing activity also is blocked by the antibody to the EGF 0
Ce 1.4
receptor [36]. We have examined two other tumors, the rat 2
FeSV tumor and the human melanoma A532. These are the C
0
tumors, respectively, from which rat and human TGFa were C) 1.2
originally purified and, in the case of the FeSV tumor, from Ce
a,
which the gene for rat TGFa was cloned. We found that animals I- 1.0
carrying either of these tumors develop hypercalcemiá.
In most of these tumors, the major bone-resorbing factor is
0.8
larger than the smallest form of TGFa. To my knowledge, all TCM TCM 1CM TCM TCM TCM TCMTCM TCM EGF EGF EGF
the tumor systems producing TGFa produce larger-molecular- ++
Ab Ab
++ ++ ++
weight forms, which probably represent unprocessed larger Ab Ab Ab Ab Ab Ab
451 310 451 310 451 310 451 310
forms of the TGFt molecule [24]. It is now well recognized, Experiment 1 Experiment 2 Experiment 3
however, that other proteins in addition to EGF and TGFa
might bind to the EGF receptor and mediate their effects Fig. 4. Effects of antisera to the EGF receptor on bone-resorbing
activity due to the Leydig cell tumor. A Antisera 451, which blocks EGF
through the EGF receptor. The most recently characterized is and TGFa biologic activity, inhibits the bone-resorbing activity pro-
the vaccinia virus protein, which is similar in size to the larger duced by the Leydig cell tumor. B Antisera 310, which does not
forms of TGFa, but which has a similar conformation to TGFa interfere with EGF binding or the biologic activity of EGF or TGFa,
and EGF and which seems to bind to, and mediate its effects has no effect on the bone-resorbing activity produced by the Leydig
tumor (From Ref. 35).
through, the EGF receptor [37].
Although different from those of TGFa, the effects of TGFI3
on bone also are interesting. Transforming growth factor 13 is a increase proteoglycan synthesis [41]. On osteoblasts they stim-
homodimer of 25,000 daltons and is secreted by most, it not all, ulate alkaline phosphatase content in osteoblast-like osteosar-
rapidly replicating cells (for review, see Ref. 38). One of its coma cells and DNA synthesis in fetal rat calvaria. No effects
most abundant sources in the human is the normal platelet, but
have yet been shown on osteoblast collagen synthesis. How-
TGF13 also has been found in bone, placenta, and kidney. There
ever these prnteins stimulate fibroblast collagen synthesis and
are two different forms found in bone, a major form and a minor
might be important in wound healing [42]. They stimulate bone
form of smaller molecular weight [39, 40]. These proteins have
resorption in mouse calvaria by increasing prostaglandin syn-
important effects not only on bone cell function but also on thesis [281, although homogenous purified preparations have
cartilage cells. They stimulate chondrocyte mitogenesis and not yet been shown to stimulate osteoclastic bone resorption in
fetal rat long bones. Thus, whether tumor-derived TGF/3 is an by indomethacin therapy. In no similar human system has a role
important mediator of the effects of tumors on the skeleton has for prostaglandins been convincingly demonstrated. Most pa-
yet to be shown, tients with the hypercalcemia of malignancy do not respond to
Parathyroid hormone-like factors. Parathyroid hormone-like indomethacin or related drugs [18]. However, in special situa-
factors are macromolecular proteins that are operationally tions in human malignancy, prostaglandins can mediate bone
defined by their capacity to bind to PTH receptors in vitro. resorption. For example, in metastatic breast cancer, the serum
They have been assayed in two ways, either by their capacity to calcium level can increase acutely following treatment with
stimulate adenylate cyclase in target cells [43—45], or by their estrogens or tamoxifen. When breast cancer cells with estrogen
capacity to stimulate G6PD content in renal tubular cells [46]. receptors are incubated in vitro with estrogens or tamoxifen,
Both of these effects can be inhibited by synthetic antagonists the cells release bone-resorbing activity, which appears to be
to PTH. It is assumed that they bind to the PTH receptor, but PGEs, as production of this activity is inhibited by indometh-
it remains conceivable that these factors could affect the acm administration [57]. Moreover, these agents cause the
receptor without binding to it. Parathyroid hormone-like factors tumor cells to release PGE [57].
are produced by many tumors associated with the hypercal- The effects of TGFa on human bone cells also might involve
cemia of malignancy and are produced by normal keratinocytes prostaglandin synthesis. In organ cultures of mouse calvaria,
[47]. The increase in nephrogenous cyclic AMP found in many for example, TGFa-induced bone resorption is inhibited by
patients with the humoral hypercalcemia of malignancy pre- indomethacin [28, 30]. But in fetal rat long bones, an alternative
sumably is due to these factors. Although some tumors that organ culture system, TGFa stimulates bone resorption inde-
produce these factors also exhibit bone-resorbing activity, such pendent of prostaglandin synthesis [27, 30]. Which of these two
activity does not appear to be mediated through the PTH systems is more applicable to human bone resorption is un-
receptor, because it is not inhibited by synthetic chemical known, but indirect production of prostaglandins could be
antagonists to PTH [48]. This finding is not surprising in the important. In 1975, Seyberth Ct al demonstrated that PGE
case of the Leydig tumor, because this tumor produces large metabolites were excreted in increased amounts in some pa-
amounts of TGFa, and the bone-resorbing activity is blocked tients with the humoral hypercalcemia of malignancy [581. The
by antisera to the TGFa!EGF receptor [35]. Similar activity has source of these prostaglandins, the mechanism for their produc-
been found in tumors of patients with oncogenic osteomalacia tion, and their effects on calcium homeostasis have still to be
[49]. The relationship among the PTH-like factors found in determined. They might be produced, for example, in target
tumors with oncogenic osteomalacia, in keratinocytes, and in cells in bone and kidney in response to agents such as the
solid tumors associated with hypercalcemia remains to be transforming growth factors. However, whether they play a
clarified. These factors have been partially purified, and the role in the pathogenesis of hypercalcemia remains to be dem-
range of molecular weights is between 10,000 and 30,000 onstrated.
daltons [44, 50]. These factors do affect the renal tubule as well Cytokines. When peripheral blood leukocytes are activated
as isolated bone cells, and it is likely that they may work in by an antigen or a mitogen such as phytohemagglutinin, bone-
concert with other factors in the pathophysiology of the resorbing activity known as osteoclast activating factor (OAF)
hypercalcemic syndrome. Some paradoxes remain, however. appears in the culture supernatants [59]. Similar bone-resorbing
Tumors associated with production of these PTH-like factors activity is released by myeloma cells [60] and by malignant
are not associated with the same abnormalities in calcium lymphoid cell lines [61]. These observations have suggested
transport across gut, kidney, and bone that are seen in primary that the bone destruction in certain hematologic malignancies is
hyperparathyroidism. For example, in patients with solid tu- the consequence of OAF release by the malignant cells. Al-
mors, gut absorption of calcium usually is decreased and 1 ,25D though many of the biologic effects of this activity on bone in
synthesis is decreased, in contrast with what occurs in primary vitro were described throughout the 1970s, final identification
hyperparathyroidism. One possible explanation for this appar- and isolation of its mediators remained difficult, as with all the
ent discrepancy is that there are several classes of PTH other known lymphokines and monokines. The advent of the
receptors [51, 521. Another possibility is that the other factors biotechnology revolution in the 1980s and the interest of the
produced by tumors associated with the hypercalcemic syn- biotechnology companies in cytokines that have potential ther-
drome oppose some of the PTH-like effects on either bone or apeutic applications have led to significant advances in the
kidney. Clarification of these discrepancies will require further understanding of bone destruction. It is apparent now that a
investigation. number of cytokines resorb bone and thus are potential mem-
Prostaglandins. Prostaglandins of the E series (PGEs) resorb bers of the OAF family. Several of these factors now have
bone in vitro, and infusions, albeit in large amounts, can clearly been documented, including interleukin-l (both alpha
increase serum calcium [53, 541. These observations suggest a and beta molecules) [62—64], lymphotoxin, and tumor necrosis
role for PGEs in the hypercalcemia of malignancy, and in factor [65]. In short-term phytohemagglutinin-activated leuko-
special situations these mediators probably are important. cyte cultures, interleukin-l probably is the mediator; Dewhirst
Convincing evidence indicates that PGEs are important in and colleagues found that the bone-resorbing factors in these
several animal models, namely the HSDM mouse fibrosarcoma culture supernatants had a partial amino acid sequence identical
and the rabbit VX2 carcinosarcoma [55, 56]. In these animal to the interleukin-l molecule of p1 7 [661. In our hands, lym-
models, cultured tumor cells produce PGEs and stimulate photoxin, tumor necrosis factor, and interleukin-l are equally
bone-resorbing activity; the PGE synthesis and the stimulated potent in the bone-resorption assay systems. The mediator of
bone-resorbing activity are inhibited by treatment with indo- OAF activity in any leukocyte culture supernatant may depend
methacin. Similarly, hypercalcemia in the animals is alleviated on the conditions of the leukocyte culture, such as cellular
composition of the leukocytes, duration of the culture, and these patients have been innoculated in nude mice, the mice
mechanisms of stimulation. Cytokines are potential mediators develop hypercalcemia and leukocytosis. Moreover, the tumor
of the bone destruction associated with malignant lymphoid extracts contain colony-stimulating factors of the granulocyte-
cells. In fact, we recently found that human myeloma cells macrophage type [81]. This colony-stimulating activity has not
freshly isolated or in culture express both lymphotoxin and been fully characterized yet, although preliminary results sug-
tumor necrosis factor mRNA, although only lymphotoxin is gest that it might be separate from the bone-resorbing activity
secreted [65]. All the bone-resorbing activity stimulated by [82]. These observations are of intense interest from several
these cultured cells in vitro could be inhibited by specific points of view. First, CSF- 1 (the lineage-specific colony-stim-
monoclonal antibodies to lymphotoxin. Lymphotoxin thus is ulating factor for cells of the monocyte family) and CSF-GM
the mediator in these particular culture systems. Whether both stimulate proliferation of mononuclear cells in long-term
lymphotoxin will prove to be the mediator of bone destruction marrow cultures. These mononuclear cells are precursors of,
in all patients with myeloma or in other types of hematologic and increase the formation of, these osteoclast-like cells [82].
malignancy is unknown but probably is unlikely. It is possible Second, Wiktor-Jedrzejczak and colleagues have shown that in
that many hematologic malignancies involving monocytic cells the opiop variant of mouse osteopetrosis, a deficiency exists in
may release interleukin-l or tumor necrosis factor as the the production of colony-stimulating activity by stromal mar-
mediators of bone destruction. row fibroblasts [83]; this deficiency presumably is responsible
1,25 Dihydroxyvitamin D. The metabolite 1,25 dihydroxyvi- for the decreased formation of osteoclasts. Third, in the meta-
tamin D is produced in the proximal tubule of the kidney in tarsal culture system developed by Burger and coworkers [84],
response to PTH or decreased ambient phosphate concentra- osteoclast formation depends on the presence of a source of
tion [671. A few cases of hypercalcemia associated with colony-stimulating activity. Fourth, since there is a large body
lymphoid malignancies in which circulating concentrations of of evidence, albeit controversial, that osteoclasts are derived
1 ,25D are increased have been documented, yet neither in- from cells of the monocyte-macrophage family, it is conceivable
creased PTH nor reduced phosphate levels are involved [14, that production of the colony-stimulating factors by tumor cells
68—70]. This finding contrasts with the vast majority of cases of could lead to both an increase in leukocyte colony formation as
the hypercalcemia of malignancy, in which 1 ,25D is decreased well as to an increase in osteoclast formation. Nevertheless
in the plasma, and calcium absorption from the gut is similarly some perplexing and unexplained issues remain. In all the cases
decreased. The lymphoid malignancies associated with in- of which I am aware, the leukocytosis is represented by a
creased 1 ,25D concentrations include adult T-cell lymphoma granulocytosis and not a monocytosis. Potential connections
and Hodgkin's disease. Some of the cases of adult T-cell between granulocytes and osteoclasts are unclear. Also this
lymphoma have been associated with the HTLV-l type-C association of leukocytosis and hypercalcemia is relatively
retrovirus infection. We have examined cultured lymphoid cells common in Japanese patients but is rare in the United States; to
infected with this virus; these cells act in every way like the my knowledge it has not been reported elsewhere in the world.
lymphoma cells carrying the virus [71, 72]. Using co-elution in The reasons for these apparent geographic or ethnic differences
a number of chromatographic systems and definitive mass are unknown. Studies of individual tumors associated with
spectrometry, we found that these cells in vitro can convert these two presumably paraneoplastic syndromes, leukocytosis
labeled 25 hydroxyvitamin D to 1,25 dihydroxyvitamin D [73]. and hypercalcemia, might lead to insights into the control of
In adults with T-cell lymphoma, 1 ,25D might be only part of the osteoclast formation and the relationships between osteoclast-
mechanism for hypercalcemia. These cells also release a bat- opoiesis and hematopoiesis.
tery of lymphokines that could be involved in the increase in The mechanisms for increased bone resorption in malignant
bone resorption [74]. Moreover, serum 1 ,25D concentrations disease are complex and likely to be heterogeneous. In many
usually are normal in hypercalcemic patients with HTLV type-i tumors it is likely that several factors act in concert on bone.
malignancies (Matsumoto T, personal communication). For example, in some solid tumors the transforming growth
In addition to this list of bone-resorbing lymphokines and factors and PTH-like factors might work together synergisti-
monokines released by normal and malignant immune cells, cally to affect bone resorption, as already has been demon-
lymphoid cells also release factors that could inhibit bone strated in vitro for PTH and EGF [85]. Moreover, these factors
resorption. Among these is gamma interferon, a powerful might be exerting their effects not just on bone but on other sites
inhibitor of osteoclastic bone resorption [75, 761. In our hands, that control regulation of serum calcium, such as kidney and
gamma interferon is more effective in inhibiting bone resorption bone.
stimulated by cytokines such as lymphotoxin, tumor necrosis
factor, and interleukin- 1 than it is in inhibiting bone resorption The role of the kidney in hypercalcemia of malignancy
stimulated by PTH. The effects of gamma interferon might be The kidney has long been considered central in the patho-
mediated via effects on cell differentiation rather than on physiology of hypercalcemia by European investigators, but it
cellular proliferation [77]. This finding might prove important has been relatively ignored until recently by Americans. The
because if it can be confirmed in vivo, gamma interferon would kidney probably plays an extremely important role in the
be a potentially useful agent in the treatment of hypercalcemia pathogenesis of hypercalcemia, producing its effects by changes
or of increased bone resorption due to mediators such as the in glomerular filtration or renal tubule calcium reabsorption.
cytokines. Decreased glomerular filtration in the presence of increased
Colony-stimulating factors. A number of cases of the hyper- bone resorption could lead to an increase in serum calcium by
calcemia of malignancy that are associated with marked leuko- simple impairment of the kidney's capacity to clear ultrafilter-
cytosis have been well documented [78, 80]. When tumors from able calcium. Glomerular filtration rate is decreased in many
patients with hypercalcemia because of volume depletion (due thyroidism. Also, the transforming growth factors could be
to emesis, poor intake, misuse of loop diuretics, etc.) as well as affecting the kidney, thereby promoting calcium reabsorption.
the renal hemodynamic effects of hypercalcemia itself. In some Epidermal growth factor promotes sodium and hydrogen ion
patients, particularly patients with myeloma, the impairment in exchange [97]. Both EGF and TGFa could be anticipated to act
glomerular filtration can be due to other causes such as Bence on the proximal tubule of the kidney, causing sodium and water
Jones nephropathy, uric acid nephropathy, or pyelonephritis reabsorption. Because calcium reabsorption in the proximal
[86]. When prerenal azotemia is present, decreased glomerular tubule is linked to sodium reabsorption, calcium reabsorption
filtration in turn leads to increased proximal renal tubular probably would be promoted by EGF, and because all the
sodium and calcium reabsorption. In myeloma, evidence sug- effects of EGF mimic those of TGFa, it is possible that TGFa
gests that the patients with the most extensive bone destruction could be producing similar effects on the renal proximal tubule.
have the highest level of OAF production in vitro by the Elucidation of the effects of tumor products on renal tubular
myeloma cells, but no positive correlation exists between OAF calcium handling will require in-vitro studies using the sophis-
production and the serum calcium [871; other factors (such as ticated techniques now available to renal physiologists. This
decreased glomerular filtration) thus probably are involved in investigative area appears to be potentially productive and even
the pathogenesis of hypercalcemia. might lead to an improved understanding of the control of
There is additional mounting evidence pointing to an increase normal renal tubular calcium handling.
in renal tubule calcium reabsorption in many patients with solid Granted that increased net renal tubule calcium reabsorption
tumors and hypercalcemia. The evidence comes from a number is an important factor in some patients with hypercalcemia, as
of clinical studies, the first recorded by Peacock et al [881; these appears incontrovertible now from the available evidence, the
investigations have confirmed that patients with solid tumors major question is its relative importance compared with other
and the hypercalcemia of malignancy have net tubular reab- factors such as increased bone resorption. One group has
sorption of calcium similar to that in primary hyperpara- attemped to develop an algorithm for determining the relative
thyroidism. This information is derived from observations on importance of increased renal tubule calcium reabsorption,
serum calcium and renal calcium excretion in patients with bone resorption, and decreased glomerular filtration [94]. This
hypercalcemia. In normal individuals, there is a curvilinear algorithm is a thoughtful attempt to sort out these complicated
relationship between ultrafilterable calcium and renal calcium issues in a setting made complex because of the limitations of
excretion [88—90]. For any given ultrafilterable calcium, a level the measurements that can be made [91].
of renal calcium excretion below the normal range indicates an
increase in net tubular calcium reabsorption, provided glomer- Role of the gut
ular filtration is normal. Although there are several limitations In normal adults in calcium balance with a stable serum
to these observations in hypercalcemic patients, nevertheless calcium, net calcium absorption from the gut is balanced by
the overall conclusions are probably correct. The limitations urinary calcium excretion. In the great majority of patients with
(reviewed in Ref. 90) are that (1) in most studies the total serum the hypercalcemia of malignancy, absorption of calcium from
calcium, rather than ultrafilterable calcium, has been measured the gut is decreased, as are circulating 1 ,25D levels [98]. In spite
(this limitation is not likely to alter significantly the conclusions of this decrease in entry of calcium into the extracellular fluid,
of most studies); (2) glomerular filtration is often impaired in in most patients the serum calcium rises progressively. This
these patients (because of dehydration or hypercalcemia per increase clearly indicates that the relative increase in bone
se); and (3) saline infusions used in the management alter renal resorption and decrease in calcium clearance by the kidneys
tubular calcium handling. In spite of these problems, the must be substantial. For example, these changes must be
observation that net renal tubular calcium reabsorption is comparatively much greater than the increase in bone resorp-
increased has been made so frequently that it seems almost tion and decreased clearance of calcium by the kidneys that are
certain to be correct. present in primary hyperparathyroidism, in which calcium
The mechanism for this putative increase in renal tubular absorption from the gut is increased. Although most tumors are
calcium reabsorption is controversial. Bijvoet and coworkers associated with decreased calcium absorption from the gut,
believe that it is predominantly due to sodium-linked calcium several exceptions have been well documented. One has al-
reabsorption in the proximal tubule that is associated with ready been mentioned, namely the lymphoid malignancies
decreases in glomerular filtration, although in their hands some associated with an increased circulating I ,25D concentration.
patients with carcinomas of the kidney or lung had an additional Another is a variant of the VX2 carcinosarcoma in the rabbit, in
specific effect on the renal tubule (personal communication). In which increased calcium absorption from the gut was clearly
contrast, other groups believe that a tumor factor promotes demonstrated [99]. In fact, in most of the animal models of the
renal tubule calcium reabsorption [9 1—96]. If tumor factors humoral hypercalcemia of malignancy, calcium absorption from
increase renal tubule calcium reabsorption, it will be interesting the gut is not decreased as it is in humans, but increased [44,
to determine which factors work in this way and what their sites 81]. This increase also occurs in some tumors in humans and in
of action are. If the PTH-like factors mimic the effects of PTH nude mice. The same tumor in humans that causes decreases in
on the kidney, as seems likely at least in some instances, then calcium absorption and l,25D concentration may cause an
we would expect distal renal tubule calcium reabsorption to be increased 1 ,25D concentration in the nude mouse. The reasons
increased. However, as has been noted before, only some of the for these disparate results are not known. One possibility is that
effects of PTH on the kidney can be ascribed to PTH-like in spite of the production of PTH-like factors and phosphate
factors. Some findings, such as the decreased 1 ,25D concentra- wasting, which would stimulate 1,25D synthesis in a normal
tions, are opposite to what is seen in primary hyperpara- individual, other factors produced by the tumor might be
interfering with this response. The only explanation for differ- the sole cellular mediator of bone resorption in metastatic
ences in behavior of the same tumor in the patient from whom malignancy. If a direct tumor cell mechanism is involved, it
it was derived and in an athymic rodent is that the effects of the
probably plays a minor part.
tumor factors might be species-specific for some target organs, DR. MICHAEL KAPLAN (Endocrinology Division, New En-
and thus might impair 1 ,25D concentration in humans but not in gland Medical Center Hospitals): In patients with myeloma,
rodents. Whatever the explanation, in most circumstances the there is no coupling of increased bone formation with bone
gut does not play an important role in the pathophysiology of resorption. Do these studies explain that finding? Second, what
hypercalcemia of malignancy. accounts for the difference between the rodent models and the
human with solid tumors, as far as 1,25 dihydroxyvitamin D
Summary production is concerned?
In summary, the hypercalcemia of malignancy is mediated by DR. MUNDY: You raise an extremely interesting and impor-
complex and heterogeneous mechanisms. Once thought of as a tant issue. The abnormalities in bone remodeling that occur in
simple paraneoplastic syndrome mediated by the effects of myeloma are different from those in other tumors. Myeloma is
tumor production of PTH [100], it is now clear that multiple characterized by marked impairment of bone formation despite
mechanisms are involved and that these mechanisms involve the increase in bone resorption. In other words, the coupling
abnormalities in calcium transport in bone, kidney, and gut. mechanism that normally links bone formation to bone resorp-
Calcium homeostasis in normal individuals is complex and tion seems to be disrupted. We do not know why this uncou-
tightly regulated. Although much has been learned over the last pling occurs, but the cytokines released by myeloma cells that
20 years about the effects of individual hormones on target resorb bone probably are unable to trigger the same sort of
organs, much remains to be understood about how these remodeling sequence that occurs, for example, in states of
hormonal systems interact to control extracellular fluid cal- parathyroid hormone excess. As you said, there are differences
cium. Future studies on disturbances in calcium homeostasis, between the rodent models and humans with respect to 1,25
such as that occurring in association with malignant disease, dihydroxyvitamin D production. In the rodent models, 1,25
should do much to clarify how these complex hormonal mech- dihydroxyvitamin D production is not suppressed, in contrast
anisms function in the normal individual. with humans with solid tumors. We don't know why there are
differences in the regulation of 1—hydroxylase activity in dif-
Questions and answers ferent species. The situation is even more complex, because
DR. JOHN T. HARRINGTON (Chief, Department of Medicine, nude mice carrying human tumors do not have suppressed 1,25
Newton-Wellesley Hospital, Newton, Massachusetts): Dr. dihydroxyvitamin D concentrations, whereas before surgical
Mundy, do we know the precise site of the increase in renal excision of the same tumors, the patients carrying these tumors
tubular calcium reabsorption? Also, what is the relative contri- have had low serum 1,25 dihydroxyvitamin D concentrations.
bution of the kidney to the hypercalcemia of malignancy? The regulatory mechanisms responsible for these differences
DR. MUNDY: We do not know where in the renal tubule the are not understood, however.
increased calcium reabsorption occurs. It would be attractive to DR. NIcoLAos E. MADIAS (Chief, Division of Nephrology,
postulate that it occurs in the distal tubule in those cases in New England Medical Center Hospitals): Recent experimental
which PTH-like factors are involved. But so far no one has evidence suggests that, under some circumstances, the level of
studied the tubular site of increased calcium reabsorption. plasma calcium concentration is an important modulator of the
Unfortunately, we do not know the relative importance of the plasma level of 1,25 dihydroxyvitamin D [1021; changes in
renal effects. John Kanis and his colleagues in Sheffield have plasma calcium produced changes in vitamin D3 in the opposite
tried to develop an algorithm to assess the relative contributions direction, at times overriding opposing influences by plasma
of bone resorption, impaired glomerular filtration, and in- phosphorus concentration and PTH. In your opinion, do these
creased renal tubular calcium reabsorption in hypercalcemic data provide any additional insight into the pathogenesis of the
patients with breast cancer [94]. Their estimates are that the depressed vitamin D3 level accompanying the hypercalcemia of
renal tubules may be responsible for approximately 30% of the malignancy?
increase in serum calcium in the hypercalcemia of breast DR. MUNDY: The observations made by Hulter et al do
cancer, suggest that long-term control of the 1,25 dihydroxyvitamin D
DR. JEROME P. KASSIRER (Associate Chairman, Department concentration might be influenced by the level of plasma
of Medicine, New England Medical Center Hospitals, Boston, calcium as well as by other factors such as parathyroid hormone
Massachusetts): Does hypercalcemia result from the physical and serum phosphorus concentrations. It is conceivable that the
destruction of bone by direct tumor invasion, or is there always suppression of the 1,25 dihydroxyvitamin D concentration in
an interpolated humoral mechanism? these tumors in humans could be related to the serum calcium
DR. MUNDY: A number of years ago I thought that it was concentration, but that does not explain why the 1,25 dihy-
likely that there was a direct cellular effect, and we showed that droxyvitamin D concentration should not be suppressed in the
human breast cancer cells could resorb devitalized bone in vitro rodent models or why the 1,25 dihydroxyvitamin D concentra-
independent of osteoclasts [101]. However, when we and Dr. tion is often increased in patients with primary hyperpara-
Alan Boyde of University College, London, later examined thyroidism.
bone surfaces from patients with metastatic cancer using scan- DR. HARRINCTON: Is there any potential therapeutic use of
ning electron microscopy, all we found was evidence of monoclonal antibodies directed either at transforming growth
osteoclastic resorption. There was no indication of non-osteo- factors or their receptors?
clast-mediated resorption. I now suspect that the osteoclast is DR. MUNDY: Not at present, although such approaches might
be possible in the future. No antibodies currently are available reverse hypercalcemia? Specifically, could you comment on
that can neutralize biologic activity due to TGFa. Antibodies to their effect on bone and tumor cells?
the receptor have been useful in our in-vitro studies, but these DR. MUNDY: Corticosteroids in pharmacologic doses inhibit
antibodies are not available for in-vivo studies either. If an bone resorption. This effect has been shown in organ culture
appropriate antibody that could neutralize biologic activity studies for many years. Steroids are particularly effective in
were available in sufficient amounts, it might be possible to use lowering serum calcium in patients with hematologic malignan-
it in this way. cies, but are much less effective in hypercalcemia associated
DR. MADIAS: Could you please summarize the principles of with parathyroid hormone excess. It appears likely that
treatment of the hypercalcemia of malignancy? corticosteroids inhibit bone resorption by interfering with the
DR. MUNDY: The principles of treatment are first, control the formation of mature osteoclasts from precursor cells.
underlying disease ii possible, and second, lower the serum DR. KAPLAN: What about the long-term use of calcitonin with
calcium with the use of therapies that promote urinary calcium steroids?
excretion or inhibit bone resorption. The choice of agents DR. MUNDY: Calcitonin and corticosteroids can be used
depends on the severity of the hypercalcemia and whether the chronically. This combination is not very convenient for long-
patient is symptomatic. term therapy because calcitonin has to be given by injection.
For patients with severe hypercalcemia and with a corrected However, it can be a good form of therapy in specific situations.
serum calcium concentration greater than 13 mg/dl, urgent For example, in a patient with myeloma and fixed impairment of
treatment is required. I prefer to use normal saline and the renal function, the choice of agents is limited if corticosteroids
combination of calcitonin and glucocorticoids in this situation. alone are ineffective. In this situation, calcitonin can be used
Normal saline promotes a sodium diuresis, and because renal effectively with corticosteroids for a number of months [81.
tubular handling of calcium and sodium is linked, the sodium However, patients will still tend to relapse unless calcitonin is
diuresis is accompanied by a calcium diuresis. Moreover, many withdrawn from time to time. One schedule we have found
patients are dehydrated at the time of admission, so fluid convenient is giving the patient corticosteroids daily but with-
replacement is necessary for this reason alone. Calcitonin and drawing calcitonin over the weekends [8].
glucocorticoids in combination are effective in up to 75% of DR. MADIAS: Are any of the factors you were discussing
patients with severe hypercalcemia. These nontoxic agents important for normal calcium homeostasis?
inhibit bone resorption and are particularly useful in patients DR. MUNDY: It is hard to know whether any of the tumor
with hematologic malignancies who have impaired renal func- products are important in normal calcium homeostasis. There is
tion. The other drugs that can be used for severe hypercalcemia no evidence that any of them are controlled by the circulating
are loop diuretics, mithramycin, and intravenous phosphate. concentration of calcium by a negative-feedback mechanism. It
Loop diuretics such as furosemide will enhance urinary calcium is likely, however, that some of these tumor factors produced
excretion but they must be used in very large doses (100 mg by their normal cellular counterparts are important for normal
every 1—2 hours) and their use may lead to other electrolyte skeletal homeostasis and in the control of osteoclast activity
problems. They should not be used until rehydration is com- during normal bone remodeling.
plete. I believe that the benefits they add over those of normal DR. KASSIRER: How carefully has the "other side of the
saline alone are not sufficient to warrant their use, unless coin" been studied? That is, what is the mechanism of calcium
patients are overhydrated or have cardiac failure. Mithramycin deposition and occasional hypocalcemia in patients with
acts less rapidly and is potentially dangerous in patients with osteoblastic metastases?
impaired renal function because it is nephrotoxic and depends DR. MUNDY: This disorder is much less common than is
on the kidney for its clearance. It usually is effective, and works hypercalcemia. Nevertheless, some tumors are associated with
by inhibiting bone resorption. Intravenous phosphate is even the production of factors that stimulate osteoblast activity and
more hazardous because of the danger of soft tissue calcifica- new bone formation, and occasionally these tumors are associ-
tion. ated with hypocalcemia. We have found that prostatic cancer
For less urgent therapy in the patient who is ambulant, the tissue sometimes produces a factor that stimulates osteoblast
choices are wider. Oral phosphate can be useful in patients who activity in vitro [1031. Of course there is great interest in
have normal renal function and a serum phosphorus less than identifying factors that stimulate bone formation, because these
4.0 mg/dl. Some patients are unable to tolerate this therapy substances might lead to therapies for patients with diseases of
because of diarrhea. Corticosteroids work in about 30% of bone loss.
patients and are most effective in patients with hematologic
malignancies. Either mithramycin or calcitonin and corticoste- Note added in proof
roids in combination can be used in ambulant patients, but these Since presentation of this Forum, two papers reporting laboratory
therapies are inconvenient because they have to be given studies on the Leydig model of hypercalcemia of malignancy have
parenterally. I predict that in the future the most widely used clearly documented the importance of renal tubular calcium reabsorp-
tion [104, 105].
agent will be one of the new bisphosphonates that currently are
being developed. These agents are used extensively in Europe Acknowledgments
and have proved effective. None is available in the United
States at present that is effective when given orally to patients The author is grateful to a number of collaborators who have helped
in these studies including Donald Bertolini, Sharyn D'Souza, Rik
with the hypercalcemia of malignancy. Derynck, James Dunn, Dianne Fetchick, Maxine Gowen, Gloria
DR. MICHAEL P. MADAIO (Division of Nephrology, New Gutierrez, Kenneth Ibbotson, Michael Katz, David Lee, David Rood-
England Medical Center Hospitals): How do corticosteroids man, George Todaro, Daniel Twardzik, Alex Valentin, and Toshiyuki
Yoneda. The work reported here was in part supported by National prostaglandin-stimulating bone-resorbing factor in vitro by human
Institutes of Health grants CA40035, AM28149, RR01346, and transitional-cell carcinoma cells. J Clin Invest 77:456—464, 1986
AM07464. The author is also grateful to Nancy Garrett for expert 20. MARQUARDT H, TODARO GJ: Human transforming growth factor:
secretarial assistance. production by a melanoma cell line, purification, and initial
characterization. J Biol Chem 257:5220—5225, 1982
Reprint requests to Dr. G. Mundy, Professor and Head, Division of 21. MARQUARDT H, HUNKAPILLER MW, HOOD LE, TODARO GJ: Rat
Endocrinology and Metabolism, The University of Texas Health transforming growth factor type I: structure and relation to
Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, epidermal growth factor. Science 223:1079—1082, 1984
Texas 78284, USA 22. TAM JP, MARQUARDT H, ROSBERGER DF, WONG TW, TODARO
GJ: Synthesis of biologically active rat transforming growth factor
References I. Nature 309:376, 1984
23. LEE DC, ROSE TM, WEBB NR, TODARO GJ: Cloning and sequence
1. Sii'so EL, MUNDY GR, D'SOUZA SM, IBBOTSON KJ, BOCK- analysis of a cDNA for rat transforming growth factor-a. Nature
MAN R, JACOBS JW: Absence of parathyroid hormone messenger 313:489-491, 1985
RNA in nonparathyroid tumors associated with hypercalcemia. N 24. DERYNCK R, ROBERTS AB, WINKLER ME, CHEN EY, GOEDDEL
Engi J Med 309:325—330, 1983 DV: Human transforming growth factor-a: Precursor structure
2. MUNDY GR, IBBOTSON KJ, D'SOUZA SM: Tumor products and and expression in E. coli. Cell 38:287—297, 1984
the hypercalcemia of malignancy. J Clin Invest 76:391—395, 1985 25. LINSLEY PS, HARGREAVES WR, TWARDZIK DR, TODARO GJ:
3. MUNDY GR, COVE DH, FISKEN R: Primary hyperparathyroidism: Detection of larger polypeptides stucturally and functionally re-
Changes in the pattern of clinical presentation. Lancet 1:317—1320, lated to Type I transforming growth factor. Proc Nat! Acad Sci
1980 USA 82:356—360, 1985
4. HEATH H III, HODGSON SF, KENNEDY MA: Primary hyperpara- 26. CARPENTER G, STOSCHECK CM, PRESTON YA, DELARCO JE
thyroidism: Incidence, morbidity, and potential economic impact Antibodies to the epidermal growth factor receptor block the
in a community. N Engi J Med 302:189—193, 1980 biological activities of sarcoma growth factor. Proc NatI Acad Sci
5. PEACOCK M, ROBERTSON WG, NORDIN BEC: Relation between USA 80:5627—5630, 1983
serum and urinary calcium with particular reference to parathy- 27. IBBOTSON KJ, TWARDZIK DR, D'SouzA SM, HARGREAVES WR,
roid hormone. Lancet 1:384—386, 1969 TODARO GJ, MUNDY GR: Stimulation of bone resorption in vitro
6. YAMAMOTO M, KAWANOBE Y, TAKAHASHI H, SHIMAZAWA E, by synthetic transforming growth factor-alpha. Science 228:
KUMURA S, OGATA E: Vitamin D deficiency and renal calcium 1007—1009, 1985
transport in the rat. J Clin Invest 74:507—513, 1984 28. TASHJIAN AH, VOELKEL EF, LAZZARO M, SINGER FR, ROBERTS
7. GARABEDIAN M, TANAKA Y, HOLICK MF, DELUCA HF: Re- AB, DERYNCK R, WINKLER ME, LEVINE L: Alpha and beta
sponse of intestinal calcium transport and bone calcium mobiliza- transforming growth factors stimulate prostaglandin production
tion to 1,25 dihydroxyvitamin D3 in thyroparathyroidectomised and bone resorption in cultured mouse calvaria. Proc NatI Acad
rats. Endocrinology 94:1022—1027, 1974 Sci USA 82:4535—4538, 1985
8. MUNDY GR, MARTIN TJ: Hypercalcemia of malignancy—Patho- 29. STERN PH, KRIEGER NS, NI55ENS0N RA, WILLIAMS RD,
genesis and treatment. Metabolism 31:1247—1277, 1982 WINKLER ME, DERYNCK R, STREWLER GJ: Human transforming
9. MUNDY UR, IBBOT5ON KJ, D'SOUZA SM, SIMPSON EL, JACOBS growth factor-alpha stimulates bone resorption in vitro. J Clin
JW, MARTIN TJ: The hypercalcemia of malignancy: Clinical Invest 76:2016—2020, 1985
implications and pathogenic mechanisms. N Engi J Med 310: 30. IBBOT5ON KJ, HARROD J, GOWEN M, D'SouzA 5, WINKLER M,
1718—1727, 1984 CARPENTER G, DERYNCK R, MUNDY GR: Effects of human
10. BROWN EM: PTH secretion in vivo and in vitro. Regulation by transforming growth factor (TGF) alpha on bone resorption and
calcium and other secretagogues. Miner Electrolyte Metab 8: formation in vitro. Proc Nat! Acad Sci USA 83:2228—2232, 1986
130--ISO, 1982 31. HON J, MUNDY GR, DERYNCK R, ROODMAN GD: Recombinant
11. MUNDY GR, BERTOLINI DB: Pathogenesis of destructive bone human transforming growth factor (TGF-a) stimulates the forma-
lesions and hypercalcemia in plasma cell myeloma. Semin Oncol tion of osteoclast (OCL)-like cells in long term human marrow
290—299, 1986 cultures. J Bone Miner Res 1:68, 1986
12. SALAHUDDIN SZ, MARKHAM PD, LINDNER SG, GOOTENBERG J, 32. SICA DA, MARTODAM RR, ARONOW J, MUNDY GR: The hyper-
POPOVIC M, HEMMI H, SARIN PS, GALLO RC: Lymphokine calcemic rat Leydig cell tumor—a model of the humoral hypercal-
production by cultured human T cells transformed by human T cemia of malignancy. Calcif Tissue Ini 35:287—293, 1983
cell leukemia-lymphoma virus-l. Science 223:703—707, 1984 33. IBBOT5ON KJ, D'SOUZA SM, NG KW, OSBORNE CK, NIALL M,
13. BERTOLINI DR, NEDWIN GE, BRINGMAN TS, MUNDY GR: Stim- MARTIN TJ, MUNDY GR: Tumor-derived growth factor increases
ulation of bone resorption and inhibition of bone formation in vitro bone resorption in a tumor associated with the humoral hypercal-
by human tumor necrosis factors. Nature 319:516—518, 1986 cemia of malignancy. Science 221:1292—1294, 1983
14. BRESLAU NA, MCGUIRE JL, ZERWEKH JE, FRENKEL EP, PAK 34. D'SOUZA SM, IBBOTSON KJ, CARPENTER G, MUNDY GR: Mech-
CYC: Hypercalcemia associated with increased serum calcitriol anisms of humoral hypercalcemia of malignancy (HHM): Use of
levels in three patients with lymphoma. Ann Intern Med 100:1—7, anti-EGF receptor antibodies and PTH antagonists (abstract).
1984 Ca!cf Tissue mt 36:480, 1984
15. FETCHICK DA, BERTOLINI DR, SARIN P, MUNDY GR, DUNN JF: 35. IBBOTSON KJ, D'SouzA SM, SMITH DD, CARPENTER G, MUNDY
Metabolism of 25—hydroxyvitamin D by human T cell lymphotro- GR: EGF receptor antiserum inhibits bone resorbing activity
phic virus-transformed cord blood lymphocytes. J Bone Miner produced by a rat Leydig cell tumor associated with the humoral
Res 1:323, 1986 hypercalcemia of malignancy. Endocrinology 116:469-471, 1985
16. VALENTIN-OPRAN A, CHARHON SA, MEUNIER PJ, EDOUARD 36. MUNDY GR, IBBOTSON KJ, D'SOUZA SM, KUKREJA SC,
CM, ARLOT ME: Quantitative histology of myeloma induced bone ABRAMSON EC, KUKLA U, CARPENTER G, DERYNCK R: Evi-
changes. Br J Haematology 52:601—610, 1982 dence that transforming growth factor alpha production causes
17. STEWART AF, VIGNERY A, SILVERGATE A, RAVIN ND, LIVOLSI bone resorption and hypercalcemia in squamous cell carcinoma of
V, BROADUS AE, BARON R: Quantitative bone histomorphometry the lung. Clin Res 33:573A, 1985
in humoral hypercalcemia of malignancy—uncoupling of bone cell 37. BROWN EM: Set-point for calcium: its role in normal and abnor-
activity. J Clin Endocrinol Metab 55:219—227, 1982 mal parathyroid secretion, in Hormonal Control of Calcium Me-
18. MUNDY GR, WILKINSON R, HEATH DA: Comparative study of tabolism, edited by COHN DV, TALMAGE RV, MATTHEWSJL,
available medical therapy for hypercalcemia of malignancy. Am J Amsterdam, Excerpta Medica, 1981, pp 35—43
Med 74:421—432, 1983 38. SPORN MB, ROBERTS AB: Autocrine growth factors and cancer.
19. BRINGHUR5T FR, BIERER BE, GODEAU F, NEYHARD N, VARNER Nature 3 13:745, 1985
V, SEGRE GV: Humoral hypercalcemia of malignancy. Release of 39. SEYEDIN SM, THOMAS TC, THOMPSON AY, ROSEN DM, PIEz
KA: Purification and characterization of two cartilage-inducing 59. HORTON JE, RAISZ LG, SIMMONS HA, OPPENHEIM JJ, MERGEN-
factors from bovine demineralized bone. Proc Nat! Acad Sci USA HAGEN SE: Bone resorbing activity in supernatant fluid from
82:2267—2271, 1985 cultured human peripheral blood leukocytes, Science 177:
40. SEYEDIN SM, THOMPSON AY, BENTZ H, ROSEN DM, MCPHER- 793—795, 1972
SON JM, CONTI A, SIEGEL NR, GALLUPPI G, PIEz KA: Carti- 60. MUNDY GR, RAISZ LG, COOPER RA, SCHECHTER GP, SALMON
lage-inducing factor-a. Apparent identity to transforming growth SE: Evidence for the secretion of an osteoclast stimulating factor
factor /3. J Biol Chem 261:5693—5695, 1986 in myeloma. N EngI J Med 291:1041—1046, 1974
41. POSER J, PFEILSCHIFTER J, COPPINGER W, LUCAS D, MUNDY G: 61. MUNDY OR, LUBEN RA, RAISZ LG, OPPENHEIM JJ, BUEL DN:
Evidence that TGF$ mediates some of the biologic activities Bone-resorbing activity in supernatants from lymphoid cell lines.
ascribed to BMP. J Bone Miner Res 1(Suppl 1):307, 1986 N EngI J Med 290:867—871, 1974
42. SPORN MB, ROBERTS AB, SHULL JH, SMITH JM, WARD JM: 62. GOWEN M, WOOD OD, IH1UE EJ, MCGuIIt MK, RUSSELL RG:
Polypeptide transforming growth factors isolated from bovine An interleukin I like factor stimulates bone resorption in vitro.
sources and used for wound healing in vivo. Science 219: Nature 306:378—380, 1983
1329—1331, 1983 63. HEATH JK, SAKLATVALA J, MEIKLE MC, ATKINSON SJ,
43. STEWART AF, INSOGNA KL, GOLTZMAN D, BROADUS AE: Iden- REYNOLDS JJ: Pig interleukin 1 (catabolln) is a potent stimulator of
tification of adenylate cyclase-stimulating activity and cytochemi- bone resorption in vitro. Calcif Tissue Int 37:95—97, 1985
cal glucose-6—phosphate dehydrogenase-stimulating activity in 64. GOWEN M, MUNDY GR: Actions of recombinant interleukin-l,
extracts of tumors from patients with humoral hypercalcemia of interleukin 2 and interferon gamma on bone resorption in vitro. J
malignancy. Proc Nail Acad Sci USA 53:941—947, 1981 Immunol 136:2478—2482, 1986
44. STREWLER GJ, WILLIAMS RD, NISSENSON RA: Human renal 65. BERTOLINI DR, NEDWIN GE, BRINGMAN T, DURIE B, GILLESTIE
carcinoma cells produce hypercalcemia in the nude mouse and a A, MUNDY GR: Evidence that tumor necrosis factor /3 (lympho-
novel protein recognized by parathyroid hormone receptors. J toxin) is the bone resorbing factor produced by myeloma cells in
Gun Invest 71:769—774, 1983 culture. J Bone Miner Res, in press
45. RODAN SB, INSOGNA KL, VIGNERY AMC, STEWART AF, 66. DEWHIRST FE, STASHENKO PP, MOLE JE, TOURUMACHI T:
BROADUS AE, D'SOUZA SM, BERTOLINI DR, MUNDY GR, Purification of partial sequences of human osteoclast activating
RODAN GA: Factors associated with humoral hypercalcemia of factor: Identity with interleukin 1 beta. J Immunol 135:2562—2568,
malignancy stimulate adenylate cyclase in osteoblastic cells. J 1985
Clin Invest 72:1511—1515, 1983 67. HAUSSLER MR, MCCAIN TA: Basic and clinical concepts related
46. GOLTZMAN D, STEWART AF, BROADUS AE: Malignancy associ- to vitamin D metabolism and action. N EngI J Med 297:974—983,
ated hypercalcemia: Evaluation with a cytochemical bioassay for 1977
parathyroid hormone. J Clin Endocrinol Metab 53:899—904, 1981 68. ROSENTHAL N, INSOGNA KL, GODSALL JW, SMALDONE L,
47. MERENDINO JJ, INSOGNA KL, MILSTONE LM, BROADUS AE, WALDRON JA, STEWART AF: Elevations in circulating 1,25 dihy-
STEWART AF: A parathyroid hormone-like protein from cultured droxyvitamin D in three patients with lymphoma-associated
human keratinocytes. Science 231:388—390, 1986 hypercalcemia. J Glin Endocrinol Metab 60:29—33, 1985
48. D'SOUZA SM, IBB0TS0N KJ, MUNDY GR: Failure of PTH antag- 69. ZALOGA GP, EIL C, MEDBERY CA: Humoral hypercalcemia in
onists to inhibit in vitro bone resorbing activity produced by two Hodgkin's disease. Arch Intern Med 145:155—157, 1985
animal models of the humoral hypercalcemia of malignancy. J Clin 70. DAVIES M, HAYES ME, MAWER EB, LUMB GA: Abnormal
Invest 74:1104—1107, 1984 vitamin D metabolism in Hodgkin's lymphoma. Lancet 1:
49. SESHADRI MS, CORNISH CJ, MASON RS, POSEN S: Parathyroid 1186—1188, 1985
hormone-like bioactivity in tumours from patients with oncogenic 71. POPOVIC M, SARIN PS, ROBERT-GURROFF M, KALYANARAMAN
osteomalacia. Gun Endocrinol 23:689—697, 1985 VS, MANN D, MINOWADA J, GALLO RC: Isolation and transmis-
50. RABBANI SA, MITCHELL J, Roy DR, KREMER R, BENNETT HPJ, sion of human retrovirus (human T-cell leukemia virus). Science
GOLTZMAN D: Purification of peptides with parathyroid hormone- 219:856—859, 1983
like bioactivity from human and rat malignancies associated with 72. REINHARDT TA, HORST RL, ORF JW, HOLLIS BW: A microassay
hypercalcemia. Endocrinology 118:1200—1210, 1986 for 1,25—dihydroxyvitamin D not requiring high performance
51. PANG PKT, YANG MCM, KEUTMANN HT, KENNY AD: Structure liquid chromatography: Application to clinical studies. J Cliii
activity relationship of parathyroid hormone: separation of the Endocrinol Metab 58:91—98, 1984
hypotensive and the hypercalcemic properties. Endocrinology 73. FETCHICK DA, BERTOLINI DR. SARIN PS, WEINTRAUB SE,
112:284—289, 1983 MUNDY OR, DUNN JR: Production of 1,25 dihydroxyvitamin D by
52. LOWIK CWGM, VAN LEEUWEN JPTM, VAN DER MEER JM, VAN human lymphotrophic virus-i transformed lymphocytes. J Clin
ZEELAND JK, SCHEVEN BAA, HERRMANN-ERLEE MPM: A two- Invest, in press
receptor model for the action of parathyroid hormone on 74. SALAHUDDIN SZ, MARKHAM PD, LINDNER SO, GOOTENBERG J,
osteoblasts: a role for intracellular free calcium and cAMP. Cell POPOVIC M, HEMMI H, SARIN PS, GALLO RC: Lymphokine
Calcium 6:311—326, 1985 production by cultured human T cells transformed by human T
53. KLEIN DC, RAI5z LG: Prostaglandins: Stimulation of bone re- cell leukemia-lymphoma virus-I. Science 223:703—707, 1984
sorption in tissue culture. Endocrinology 86:1436—1440, 1970 75. JILKA RL, HAMILTON JW: Inhibition of parathormone-stimulated
54. FRANKLIN RB, TASHJIAN AH: Intravenous infusion of prostaglan- bone resorption by Type I interferon. Biochem Biophys Res
din E2 raises plasma calcium concentration in the rat. Endocrinol- Gommun 120:553—558, 1984
ogy 97:240—243, 1975 76. GOWEN M, NEDWIN GE, MUNDY OR: Preferential inhibition of
55. TASHJIAN AH, V0ELKEL EF, LEVINE L, GOLDHABER P: Evidence cytokine-stimulated bone resorption by recombinant interferon
that the bone resorption-stimulating factor produced by mouse gamma (abstract). J Bone Miner Res l:#67, 1986
fibrosarcoma cells is prostaglandin E2: A new model for the 77. ROODMAN GD, TAKAHASHI N, MUNDY GR: Recombinant human
hypercalcemia of cancer. J Exp Med 136:1329—1343, 1972 interferon (y-IFN) inhibits formation of osteoclast (OCL)-like cells
56. VOELKEL EF, TASHJIAN AH, FRANKLIN R, WASSERMAN E, by inhibiting the fusion of their precursors. Clin Res 34:522A, 1986
LEVINE L: Hypercalcemia and tumor-prostaglandins: the VX2 78. LEE MY, BAYLINK DJ: Hypercalcemia, excessive bone resorp-
carcinoma model in the rabbit. Metabolism 24:973—986, 1975 tion, and neutrophilia in mice bearing a mammary carcinoma.
57. VALENTIN A, EIL0N 0, SAEZ 5, MUNDY GR: Estrogens and Proc Soc Exp Biol Med 172:424—429, 1983
anti-estrogens stimulate release of bone resorbing activity by 79. KONDO Y, SATO K, OHKAWA H, UEYAMA Y, OKABE T, SATO N,
cultured human breast cancer cells. J Clin Invest 75:726-731, 1985 ASANO S, M0RI M, OHSAWA N, KOSAKA K: Association of
58. SEYBERTH HW, SEGRE GV, MORGAN JL, SWEETMAN BJ, Porrs hypercaicemia with tumors producing colony-stimulating fac-
iT, OATES JA: Prostaglandins as mediators of hypercalcemia tor(s). Cancer Res 43:2368—2374, 1983
associated with certain types of cancer. N EngI J Med 293: 80. O5HAWA N, UEYAMA Y, MORITA K, KONDO Y: Heterotransplan-
1278—1283, 1975 tation of human functioning tumors to nude mice, in Proceedings
of the Second International Workshop on Nude Mice, edited by 93. RALS-ON SH, FOGELMAN I, GARDNER MD, DRYBURGH FJ,
NOMURA T, OSHAWA N, TAMAOKA N, FUJIWARA F, Tokyo, COWAN RA, BOYLE IT: Hypercalcemia of malignancy: evidence
University of Tokyo Press, 1977, pp 395—405 for a non-parathyroid agent with an effect on renal tubular
81. SATO K, MlMuIt H, HAN DC, KAKIUCHI T, UEYAMA Y, handling of calcium. Clin Sci 66:187—191, 1984
OHKAWA H, OKABE T, KONDO Y, OHSAWA N, TSUSHIMA T, 94. PERCIVAL RC, YATES AJP, GRAY RES, GALLOWAY J, ROGERS K,
SHIZUME K: Production of bone resorbing activity and colony NEAL FE, KANIS JA: Mechanisms of malignant hypercalcemia in
stimulating activity in vivo and in vitro by a human squamous cell carcinoma of the breast. Br Med J 291:776-779, 1985
carcinoma associated with hypercalcemia and leukocytosis. J Clin 95. PEACOCK M, SELBY PL, GIBBS CJ, AARON JE: Pathogenesis of
Invest, in press neoplastic hypercalcemia. Calcif Tissue ml (suppl) 38:S37, 1985
82. MACDONALD BR, MUNDY GR, CLARK S, WANG EA, ROODMAN 96. CAVERZASIO J, Rizzou R, FLEISCH H, BONJOUR J-P: PTH like
GD: Recombinant human hemopoietic colony stimulating factor changes of renal calcium and phosphate (Pi) reabsorption induced
increases the number of osteoclast-like cells in long-term marrow by Leydig cell tumor in thyroparathyroidectomized (TPTX)
cultures. J Bone Miner Res 1:143, 1986 Fischer rats. Calcif Tissue ml (suppl) 36:S26, 1984
83. WIKTOR-JEDRZEJZCAK W, AHMED A, SZCZYLIK C, SKELLY RR: 97. MOOLENAAR WH, TSIEN RY, VAN DER SAAG PT, DE LAAT SW:
Hematological characterization of congenital osteopetrosis in Na + /HT exchange and cytoplasmic pH in the action of growth
op/op mouse. J Exp Med 156:1516—1527, 1982 factors in human fibroblasts. Nature 304:645—648, 1983
84. BURGER EH, VAN DER MEER JWM, VAN DE GEVEL JS, GRIBNAU 98. STEWART AF, HORST R, DEFTOS U, CADMAN EC, LANG R,
JC, THEsINGH CW, VAN FURTH R: In vitro formation of BROADUS AE: Biochemical evaluation of patients with cancer-
osteoclasts from long term bone cultures of bone marrow mono- associated hypercalcemia: evidence for humoral and nonhumoral
nuclear phagocytes. J Exp Med 156:1604-1614, 1982 groups. NEnglJMed3O3:1377—1383, 1980
85. LORENZ0 JA, QUINTON J: Epidermal growth factor enhances the 99. DOPPELT SH, SLOvIK DM, NEER RM, NOLAN J: Gut-mediated
resorptive response to parathyroid hormone. Calcif Tissue ml hypercalcemia in rabbits bearing VX2—carcinoma—New mecha-
36:465, 1984 nism for tumor-induced hypercalcemia. Proc Natl Acad Sci USA
86. HEYBURN PJ, CHILD JA, PEACOCK M: Relative importance of 79:640—644, 1982
renal failure and increased bone resorption in the hypercalcemia of 100. LAFFERTY FW: Pseudohyperparathyroidism. Medicine 45:247—
myelomatosis. J Clin Pathol 34:54—57, 1981 260, 1966
87. DURIE BGM, SALMON SE, MUNDY GR: Relation of osteoclast 101. EILON G, MUNDY GR: Direct resorption of bone by human breast
activating factor production to the extent of bone disease in cancer cells in vitro. Nature 276:726—728, 1978
multiple myeloma. Br J Haematol 47:21—30, 1981 102. HULTER HN, HALLORAN BP, ToTo RD, PETERSON JC Long-
88. PEACOCK M, ROBERTSON WG, NORDIN BEC: Relation between term control of plasma calcitrol concentration in dogs and hu-
serum and urine calcium with particular reference to parathyroid mans. Dominant role of plasma calcium concentration in experi-
activity. Lancet 1:384—386, 1969 mental hyperparathyroidism. J Clin Invest 76:695—702, 1985
89. NORDIN BEC: Calcium phosphate and magnesium metabolism. 103. SIMPSON EL, HARROD J, EILON G, JACOBS JW, MUNDY GR:
Clinical physiology and diagnostic procedures. Edinburgh, Identification of a mRNA fraction in human prostatic cancer cells
Churchill Livingstone, 1976 coding for a novel osteoblast-stimulating factor. Endocrinology
90. KLEEMAN CR, BERNSTEIN D, ROCKNEY R, DOWLING JT, MAX-
WELL MH: Studies on the renal clearance of diffusible calcium and 117:1615—1620, 1985
the role of the parathyroid glands in its regulation. Yale JBiol Med 104. HIRSCHEL-SCHOLZ 5, CAVERZASIO J, Rizzoi R, BONJOUR J-P
34: 1—30, 1961 Normalization of hypercalcemia associated with a decrease in
91. KANIS JA, CUNDY T, HEYNEN G, RUSSELL RGG: The pathophys- renal calcium reabsorption in Leydig cell tumor-bearing rats
iology of hypercalcemia. Metab Bone Dis Relat Res 2: 15 1—159, treated with WR-2721. J Clin Invest 78:319—322, 1986
1980 105. RIzzoLl R, CAVERZASIO J, FLEISCH H, BONJOUR J-P: Parathyroid
92. RALSTON SH, FOGELMAN I, GARDNER MD, BOYLE IT: Relative hormone-like changes in renal calcium and phosphate reabsorp-
contribution of humoral and metastatic factors to the pathogenesis tion induced by Leydig cell tumor in thyroparathyroidectomized
of hypercalcemia in malignancy. Br Med J 288:1405—1408, 1984 rats. Endocrinology 119:1004—1009, 1986

Pi Is 0085253815338837

Uploaded by

Copyright:

Available Formats

Pi Is 0085253815338837

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pi Is 0085253815338837

Uploaded by

Copyright:

Available Formats

Kidney International, Vol. 31(1987), pp.

The hypercalcemia of malignancy

The University of Texas Health Science Center, San Antonio, Texas

mg/dl. Plasma PTH (C-terminal) was 50 zEq/ml (normal, 20—120

DR. GREGORY R. MUNDY (Head, Division of Endocrinology

in which the secretion of the tumors is constrained by feedback

patients with cancer.

in concentrations as low as 0.01 ng/ml, the lowest concentration A

You might also like

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.