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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 3  |  Page : 245-246

Parathyroid carcinoma: Atypical presentation and coexistence with papillary thyroid cancer


Department of Medicine, King Abdul-Aziz Medical City, Jeddah, Kingdom of Saudi Arabia

Date of Web Publication3-Aug-2015

Correspondence Address:
Salhah S Al-Sulami
Department of Medicine, P. O. Box: 9515, King Abdul-Aziz Medical City, Jeddah 21423
Kingdom of Saudi Arabia
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DOI: 10.4103/1658-631X.162042

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  Abstract 

This is a case of parathyroid carcinoma after investigating for neck mass with surprisingly high parathyroid hormone (PTH) and normal calcium levels. After ultrasound localization, the patient underwent left hemi-Parathyroidectomy and left hemithyroidectomy. The patient's calcium level was normal throughout the follow-up period, but she later developed hypercalcemia, which did not require any specific treatment. Complete surgery was not an option in her case as metastasis work up revealed diffuse metastasis.

  Abstract in Arabic 



ملخص البحث:
يستعرض الباحث حالة سرطان الغدة جارة الدرقية. تم فحص المريضة المصابة وتبين وجود كتلة في الرقبة مع ارتفاع في هرمون الغدة، وكان مستوى الكالسيوم في الدم طبيعياً. أثبتت الفحوصات والأشعة الصوتية وجود ورم حيث تم استئصاله. ووضح فحص الأنسجة خلايا سرطانية. وبالرغم من الارتفاع الشديد لهرمون الغدة جارة الدرقية إلا أن مستوى الكالسيوم في الدم حافظ لم يرتفع خلال فترة متابعة المريضة والتي تجاوزت السنتين. وبعدها ارتفع إلى مستوى لم يحتاج إلى تدخل علاجي. يعتبر هذا من الحالات النادرة جدا ونظراً لانتشار الورم في الجسم فلم يكن هناك إمكانية لإجراء عملية استئصاليه.

Keywords: Parathyroid carcinoma, metastasis, papillary thyroid cancer


How to cite this article:
Al-Sulami SS. Parathyroid carcinoma: Atypical presentation and coexistence with papillary thyroid cancer. Saudi J Med Med Sci 2015;3:245-6

How to cite this URL:
Al-Sulami SS. Parathyroid carcinoma: Atypical presentation and coexistence with papillary thyroid cancer. Saudi J Med Med Sci [serial online] 2015 [cited 2020 Nov 27];3:245-6. Available from: https://www.sjmms.net/text.asp?2015/3/3/245/162042


  Learning points Top


  • Parathyroid cancer is a rare cause of primary hyperparathyroidism and often presented with markedly elevated parathyroid hormone (PTH).
  • Hypercalcemia of parathyroid carcinoma can be masked with Vitamin D deficiency.
  • Parathyroid cancer may coexist with papillary thyroid cancer.

  Background Top


Parathyroid carcinoma is a rare cause of hyperparathyroidism. [1] It commonly presents with symptomatic hypercalcemia and uncommonly with symptoms of the invasion of local tissue. There have been reported cases of concomitant thyroid and parathyroid pathology in which a complete surgical resection remained the only potential curative option.


  Case presentation Top


This is a case of a 75-year-old female patient first referred to a surgery clinic for a neck mass. She was seen for the first time in the clinic in February 2012 with work-up that revealed a normal calcium level with two normal documented values of adjusted calcium (2.34 mmol/L and 2.38 mmol/L (ref. 2.21-2.55 mmol/L). Retrospective questioning revealed no symptoms of polyuria, polydipsia, nocturia, kidney stones or fracture.

9 months later, there was the first documentation of abnormally high calcium profile of 2.82 mmol/L, and low phosphorous of 0.67 (0.74-1.52 mmol/L) with concomitant high value of PTH of 1774 pg/ml (ref: 10-69 pg/ml). No Vitamin D level was measured at that time. Serum Creatinine was 104 mmol/L. At that time, the patient was referred for a neck ultrasound to identify the nature of the mass. This showed evidence of left parathyroid mass which was likewise localized by 99 m Tc sestamibi scan. She was booked for parathyroidectomy, but she was reluctant to do so.

The patient eventually agreed to the surgery and underwent left hemithyroidectomy and parathyroidectomy. Histopathology revealed parathyroid carcinoma (3.5 cm mass) with extensive invasion, positive surgical margins, and positive angiolymphatic invasion with three foci of papillary thyroid carcinoma, the largest of which was 0.5 cm.


  Investigation Top


During the period of follow-up, the highest calcium level reached was 2.82 mmol/L which normalized postoperatively to 2.37 mmol/L. Also, PTH dropped from 1774 pg/ml to 200 pg/ml postoperative.

Computed tomography scan of the abdomen and pelvis showed multiple bony lesions which could be explained by hyperparathyroidism or metastasis. Bone scan confirmed extensive bony metastasis in the skull, right humerus, multiple ribs, vertebrae, pelvis, and left tibia.


  Treatment Top


During 2 years of follow-up prior to surgery, the patient did not have any symptomatic hypercalcemia. Furthermore, she didn't develop any complications related to hypercalcemia. She was kept in the hospital for 4 days postoperative without any immediate postoperative complications or hypocalcemia.


  Outcome and follow-up Top


From February, 2012 through March, 2014, the patient did not develop any significant hypercalcemia requiring medical attention despite very high PTH.

After the above findings had been documented, the decision for complete parathyroidectomy was out of choice, especially since there was a diffuse distant metastasis.

On long-term follow-up, she was offered ergocalciferol 50,000 IU to replenish her stores, and treated with alendronate 70 mg weekly for osteoporosis.

There was no further follow-up.


  Discussion Top


The overwhelming majority of parathyroid cancers are functioning tumors. Therefore, patients most often present with symptoms and signs of hypercalcemia. [2],[3],[4],[5],[6] Our patient was referred initially for a neck mass without hypercalcemia and was found to have a very high PTH level, which is extremely rare with parathyroid carcinoma. In our patient, Vitamin D deficiency might have masked the picture of hypercalcemia.

It is not known if there are specific risk factors associated with parathyroid carcinoma, but notably, neck irradiation is a risk factor for parathyroid carcinoma. Our patient had no previous history of neck irradiation nor any other known risk factors for parathyroid or thyroid carcinoma, and she had no family history of multiple endocrine neoplasia type 1, 2A or 2B syndromes.

Coexisting thyroid carcinoma is extremely rare. [7] Documented cases of synchronous parathyroid and thyroid carcinomas have been reported. [8],[9]

 
  References Top

1.
Wei CH, Harari A. Parathyroid carcinoma: Update and guidelines for management. Curr Treat Options Oncol 2012;13:11-23.  Back to cited text no. 1
    
2.
Rao SR, Shaha AR, Singh B, Rinaldo A, Ferlito A. Management of cancer of the parathyroid. Acta Otolaryngol 2002;122:448-52.  Back to cited text no. 2
    
3.
Wynne AG, van Heerden J, Carney JA, Fitzpatrick LA. Parathyroid carcinoma: Clinical and pathologic features in 43 patients. Medicine (Baltimore) 1992;71:197-205.  Back to cited text no. 3
    
4.
Shane E. Clinical review 122: Parathyroid carcinoma. J Clin Endocrinol Metab 2001;86:485-93.  Back to cited text no. 4
    
5.
Fujimoto Y, Obara T. How to recognize and treat parathyroid carcinoma. Surg Clin North Am 1987;67:343-57.  Back to cited text no. 5
[PUBMED]    
6.
Holmes EC, Morton DL, Ketcham AS. Parathyroid carcinoma: A collective review. Ann Surg 1969;169:631-40.  Back to cited text no. 6
    
7.
Fernandez-Ranvier GG, Khanafshar E, Jensen K, Zarnegar R, Lee J, Kebebew E, et al. Parathyroid carcinoma, atypical parathyroid adenoma, or parathyromatosis? Cancer 2007;110:255-64.  Back to cited text no. 7
    
8.
Kurita S, Mihashi S, Hirano M, Nakashima T, Tanimura A. Hyper functioning parathyroid carcinoma combined with papillary carcinoma of the thyroid gland. J Jpn Soc Cancer Ther 1979;14:1127-35.  Back to cited text no. 8
    
9.
Lin SD, Tu ST, Hsu SR, Chang JH, Yang KT, Yang LH. Synchronous parathyroid and papillary thyroid carcinoma. J Chin Med Assoc 2005;68:87-91.  Back to cited text no. 9
    




 

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  In this article
   Abstract
  Learning points
  Background
  Case presentation
  Investigation
  Treatment
  Discussion
   Outcome and foll...
   References

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