0021-972X/99/$03.00/0
Journal of Clinical Endocrinology and Metabolism
Copyright © 1999 by The Endocrine Society
Vol. 84, No. 2
Printed in U.S.A.
COMMENTS
Inability of Short-Term, Low-Dose Hydroxychloroquine
to Resolve Vitamin D-Mediated Hypercalcemia in
Patients with B-Cell Lymphoma*
JOHN S. ADAMS
AND
VITALY KANTOROVICH
The Burns and Allen Research Institute and Division of Endocrinology and Metabolism, Cedars-Sinai
Medical Center, University of California Los Angeles, Los Angeles, California 90048
ABSTRACT
The 4-aminoquinolines, including chloroquine and hydroxychloroquine, have been successfully employed to treat patients with granuloma-forming disease-associated, vitamin D metabolite-mediated
hypercalcemia. The calcium-lowering efficacy of these drugs has not
been prospectively evaluated in patients with lymphoma and elevated
1,25-(OH)2D levels. Four such hypercalcemic patients with stage IV
B-cell lymphoma were treated, two each, with either 400 mg daily oral
hydroxychloroquine or a single course of prednisone-containing antitumor chemotherapy (CHOP). Antitumor therapy normalized the
serum calcium and 1,25-(OH)2D concentration within 5 days. Over a
15-day period, hydroxychloroquine failed to reduce either the serum
calcium or 1,25-(OH)2D level in lymphoma patients. In contrast,
within 5 days 400 mg of hydroxychloroquine daily lowered elevated
levels of calcium and 1,25-(OH)2D by 37% and 72%, respectively, in
a hypercalcemic patient with sarcoidosis. These data suggest that
regulation of the vitamin D-1-hydroxylase in lymphoma cells, the
putative source of hormone in lymphoma patients, is refractory to the
inhibitory actions of the aminoquinolines and that glucocorticoidcontaining antitumor regimens are the antihypercalcemic therapies
of choice in lymphoma patients with high 1,25-(OH)2D levels. (J Clin
Endocrinol Metab 84: 799 – 801, 1999)
H
YPERCALCEMIA complicates the clinical course of a
substantial number of patients with widespread lymphoproliferative disorders, including lymphomas and the
granuloma-forming diseases like sarcoidosis (1–5). In many
instances, the underlying cause of hypercalcemia is the endogenous overproduction of the active vitamin D metabolite,
1,25-dihydroxyvitamin D (1,25-(OH)2D). Successful management of hypercalcemia in patients with sarcoidosis can be
achieved with oral administration of the 4-aminoquinoline
agents, chloroquine (6) and hydroxychloroquine (7). We previously demonstrated that low dose, twice-daily chloroquine
treatment could restore calcium balance to normal in the
matter of only a few days (8). Because this therapeutic regimen was simple, well tolerated and rapid, we proposed to
undertake a similar trial in patients with lymphoma-associated, 1,25-(OH)2D-mediated hypercalcemia. Compared with
antitumor chemotherapy, a preliminary trial of this regimen
in two hypercalcemic lymphoma patients failed to resolve
hypercalcemia and to reduce inappropriately elevated serum
concentrations of 1,25-(OH)2D.
cleaved B-cell lymphoma is presented in Table 1. Two patients refused
chemotherapy and were treated with hydroxychloroquine 200 mg orally
twice daily for 15 days. Two other patients were evaluated over the same
period following a single course of antitumor chemotherapy with cyclophosphamide, hydroxydaunorubicin, oncovin (vincristine), and
prednisone (CHOP). Informed consent was obtained from all subjects
before initiation of the protocol. The protocol was approved by both the
Institutional Review Board and Scientific Advisory Committee of Cedars-Sinai General Clinical Research Center (GCRC). All subjects were
monitored on an outpatient basis in the GCRC before and after initiation
of hydroxychloroquine or CHOP. Patient 2 (Table 1) expired on day 15
of hydroxychloroquine treatment. A 36-yr-old hypercalcemic patient
with biopsy-proven, active sarcoidosis was also studied via the same
protocol for confirmation of the efficacy of the calcium- and 1,25(OH)2D-lowering potential of the hydroxychloroquine regimen. Serial
serum calcium, albumin, and creatinine as well as urine (on both 2-h
fasting and 24-h samples) calcium and creatinine were measured by
automated technologies. The serum 25-hydroxyvitamin D (25-OHD)
and 1,25-(OH)2D concentration was determined by competitive protein
binding assay and radioreceptor assay, respectively (Nichols Institute
Diagnostics, San Juan Capistrano, CA). PTH and PTH-related peptide
(PTHrP) were measured by two-site chemiluminescent (Endocrine Sciences, Inc., Calabasas Hills, CA).
Results
Experimental Subjects
Before therapy, suppressed serum concentrations of PTH
(, 10 pg/mL, normal 10 – 65 pg/mL), nonelevated levels of
PTHrP (, 1.0 pg/mL; normal , 1.3 pg/mL) and nonelevated
levels of 25-OHD (, 36 ng/mL; normal 10 –55 ng/mL) were
confirmed in all subjects. The serum creatinine was maintained # 2.5 gm/dL (normal , 1.5 gm/dL) at all times in all
patients. Serum samples were stored at 270° C before assay.
All samples from an individual subject were analyzed in the
same assay to obviate interassay variation. The serum calcium (corrected for serum albumin) and 1,25-(OH)2D levels
The sex, age, classification of lymphoma by type and state, and mode
of antihypercalcemic therapy of four patients with stage IV small nonReceived July 7, 1998. Revision received October 26, 1998. Accepted
October 29, 1998.
Address correspondence and requests for reprints to: John S. Adams,
M.D., B131, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los
Angeles, California 90048.
* This work was supported in part by General Clinical Research
Center Grant 00425–28 and AI-40403 from the National Institutes of
Health.
799
800
COMMENTS
in four hypercalcemic patients with lymphoma was followed
for up to 20 days following administration of hydroxychloroquine or antitumor chemotherapy with CHOP (Fig. 1). The
two patients who were initiated on twice daily oral administration of 200 mg hydroxychloroquine failed to normalize
either the corrected serum calcium or the serum 1,25-(OH)2D
concentration over a 2- to 3-week observation period. By
comparison, successful antitumor chemotherapy was effective in restoring normal calcium homeostasis in the two other
patients with neoplasms of similar type and extent. Restoration of the serum calcium and 1,25-(OH)2D levels to the
normal range (Fig. 1) and return of the urinary calcium:
creatinine excretion ratio to #0.10 occurred within 5 days of
initiation of chemotherapy in both patients. A similar time
frame for correction of the parameters was observed in a
hypercalcemic patient with active sarcoidosis (Fig. 1); this
patient’s response confirms the efficacy of the hydroxychloroquine regimen to rapidly correct deregulated extrarenal
vitamin D synthesis in a granuloma-forming disease.
Discussion
Hypercalcemia is a complication of lymphoma, particularly wide-spread B-cell neoplasms (9). In the largest prospectively analyzed cohort of hypercalcemic lymphoma patients (10), the incidence of 1,25-(OH)2D-mediated
hypercalcemia was 55%. In patients with granuloma-forming diseases like sarcoidosis as well as in patients with maTABLE 1. Patients with lymphoma and 1,25-dihydroxyvitamin
D-mediated hypercalcemia
Patienta
Sex
Age
Lymphomab
Stageb
Treatment
1
2
3
4
M
F
F
F
29
77
74
67
SNC-B
SNC-B
SNC-B
SNC-B
IV
IV
IV
IV
Hydroxychloroquine
Hydroxychloroquine
CHOP
CHOP
a
The patient identifier number shown here corresponds to individual data depicted in Fig. 1.
b
SNC-B stands for high grade, small-noncleaved B-cell according
to the Working Formulation; all tumors were disseminated or Stage
IV according to the Ann Arbor staging system.
FIG. 1 Serum calcium (left panel) and
1,25-dihydroxyvitamin D levels (right
panel) in four lymphoma patients with
hypercalcemia; the numbers correspond to patients identified in Table 1.
Patients were treated with hydroxychloroquine 200 mg twice daily (HCQ,
dark squares) or the chemotherapeutic
regimen CHOP (CT, shaded squares).
For comparison are similar data from a
hypercalcemic patient with sarcoidosis
treated with hydroxychloroquine 200
mg twice daily (HCQ, open squares).
The total serum calcium concentration
was corrected for the serum albumin
concentration according to the formula,
measured serum calcium 1 0.8 (4.0 2
measured serum albumin). Shaded regions represent the range of normal
values.
JCE & M • 1999
Vol 84 • No 2
lignant lymphoproliferative disorders, like the B-cell lymphoma patients examined here, the source of the vitamin D
hormone is believed to be extrarenal (11). This supposition
is based on three central observations. First, hypercalcemia
persists in the presence of suppressed PTH and elevated
1,25-(OH)2D concentrations; PTH and 1,25-(OH)2D are the
major stimulator and inhibitor of the renal vitamin D-1 hydroxylase, respectively (12). Second, functionally anephric
patients with these disorders can develop 1,25-(OH)2D-mediated hypercalcemia (13). Third, administration of an antiinflammatory dose of glucocorticoid is the most effective
means of reducing the serum calcium and 1,25-(OH)2D levels
in lymphoma patients (9) as well as in patients with
granuloma-forming diseases (5).
Because inflammatory cells were the presumed source of
hormone in both granuloma-forming and malignant lymphoproliferative diseases, we hypothesized that the 4-aminoquinoline derivatives would be as efficacious in lowering
1,25-(OH)2D and calcium levels in B-cell lymphoma patients
as they are in patients with granuloma-forming diseases.
This hypothesis appears to be incorrect, as the vitamin D-1hydroxylase activity in lymphoma cells, the putative source
of hormone in lymphoma patients, is refractory to the inhibitory actions of the aminoquinolines (Fig. 1). It is possible
that failure to achieve normocalcemia in lymphoma patients
with this regimen is due to 1) an inadequate dose of the drug;
2) inadequate duration of therapy; and/or 3) a relatively
greater burden of the 1-hydroxylase compared with patients
with granuloma-forming diseases like sarcoidosis. Alternatively, insensitivity of the hypercalcemic lymphoma patient
to hydroxychloroquine may be principally due to a difference in the cell in which the hydroxylase gene is expressed.
In macrophages, the 1,25-(OH)2D synthetic site in human
granuloma-forming disease (14), the chloroquine-sensitive
phospholipase C (PLC) pathway (15) and inducible nitric
oxide synthase (iNOS) pathway (16, 17) are considered to be
key regulators of the enzyme. These same signal transduction pathways may not be as highly expressed or involved
COMMENTS
in 1-hydroxylase regulation in the lymphoma cell as they are
in the macrophage.
In conclusion, we have shown that, compared with a patient with active sarcoidosis, short-term (2 weeks), low-dose
hydroxychloroquine administration at well tolerated doses is
an ineffective calcium lowering regimen in patients with
non-Hodgkins B-cell lymphoma and 1,25-(OH)2D-mediated
hypercalcemia. In such patients, glucocorticoid-containing
antitumor regimens should be considered the antihypercalcemic therapy of choice.
7.
8.
9.
10.
11.
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4517.
International Thyroid Symposium
in Honor of Lewis E. Braverman, M.D.
Palm Beach, Florida, September 29, 1999
A symposium in honor of Lewis E. Braverman, M.D. has been organized for Wednesday, September 29, 1999,
from 8:30 AM to 6:00 PM at the Breakers Hotel, Palm Beach, Florida, just prior to the 1999 Meeting of the
American Thyroid Association. Topics will include areas in which Dr. Braverman has made important
contributions to clinical and basic thyroidology: iodine, bone, cancer, thyroid hormone action and metabolism, and Grave’s Disease. The Organizing Committee includes: Wiliam W. Chin, M.D., Alan P. Farwell,
M.D., Aldo Pinchera, M.D., Shigenobu Nagataki, M.D., and Elio Roti, M.D. There will be no registration fee.
We invite those who wish to attend to contact Katherine Caldwell, Division of Genetics, Brigham & Women’s
Hospital, 75 Francis Street, Boston, MA 02115; Phone (617) 732-5856; Fax: (617) 732-5123 or E-mail:
[email protected].