Parathyroid carcinoma and persistent hypercalcemia: A case report and review of therapeutic options (original) (raw)
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Case Reports in Medicine, 2014
Context.Severe hypercalcemia is a life-threatening condition. Atypical parathyroid adenoma and parathyroid carcinomas are uncommon causes which can be difficult to differentiate.Objective.We report a case of a 36-year-old male with very high serum calcium due to a possible atypical parathyroid adenoma versus parathyroid carcinoma.Case Illustration.A serum calcium level of 23.2 mg/dl was noted on admission. He was initially treated with IV hydration, pamidronate, and salmon calcitonin to lower his calcium levels. He also underwent a surgical en bloc resection of parathyroid mass. Pathology showed a mixed picture consistent with possible atypical adenoma versus parathyroid carcinoma. However, due to the possible involvement of the recurrent laryngeal nerve, parathyroid carcinoma was more likely. Also after operation the patient developed hungry bones syndrome and his calcium was replaced vigorously. He continues to be on calcium, vitamin D, and calcitriol supplementation.Results.A rev...
Hypercalcemia And Metastic Parathyroid Carcinoma: Diagnostic Challenge
Parathyroid carcinoma is an extremely rare neoplasm which typically is associated with hardened nodules in the parathyroid region, hypercalcemia and renal failure. A 69 year-old woman presented with knee pain at an emergency unity. On clinical examination the patient also presented a 2.0cm fibroelastic and mobile node in the left neck, level II. Serum total calcium and parathyroid hormone were increased, and the node was also detected by CT and 99mTc-sestamib scintigraphy. The patient had been surgically previously treated of parathyroid carcinoma misdiagnosed as a thyroid adenoma (eleven years ago), and a hyperplasia of parathyroid chief cells (nine years ago), that after revision was diagnosed as cervical metastasis of parathyroid carcinoma. She was surgically treated by neck dissection, confirming the second regional metastasis of parathyroid carcinoma. The diagnosis of parathyroid carcinoma is a challenge, and although rare, it should be considered in the presence of hypercalcemia and palpable neck nodule. Key Words: Parathyroid Carcinoma; Hypercalcemia; Hyperparathyroidism; Lymph Node Metastasis; Nodule
The Annals of The Royal College of Surgeons of England, 2020
Introduction Hypercalcaemic crisis is a rare manifestation of hyperparathyroidism and occurs in 1.6–6% of patients with primary hyperparathyroidism (pHPT). Although such high serum calcium levels (>14mg/dl) are attributed to malignancy, it is also associated with benign disease of the parathyroid glands. The aim of this study was to evaluate the clinical features and treatment modalities of patients with severe hypercalcaemia who underwent surgery for pHPT. Methods The medical records of 537 patients who underwent parathyroidectomy in our department for pHPT between 2005 and 2019 were reviewed retrospectively. Twenty-four (4.4%) of the patients were described as having severe hypercalcaemia. Results Among 24 patients, 71% were female and the mean age was 55.7 years (range: 40–71 years). The mean serum calcium level at time of diagnosis was 15.9mg/dl (range: 14–22.7mg/dl). According to postoperative pathology reports, solitary adenoma, parathyroid cancer and parathyromatosis were ...
Journal of Medical Cases, 2013
Atypical parathyroid adenoma is among the tumors diagnosed difficultly and including some histological features of parathyroid carcinoma. In literature, no definite criteria have been considered to be present to distinguish atypical parathyroid adenoma preoperatively from parathyroid carcinoma. A 65-year-old woman was admitted to our clinic with complaints of arthralgia, myalgia, fatigue and loss of appetite. She had severe hypercalcemia (serum calcium 17.2 mg/dL) and hypophosphatemia (serum phosphate 1.9 mg/dL) along with an elevated intact parathyroid hormone level of 879 pg/mL. Renal functions were within normal limits. The patient was administered with intravenous hydration and diuretic treatments because of severe hypercalcemia. Six sessions of hemodialysis were performed. In neck ultrasonography, multinodular goitre was detected. Tc-99m sestamibi scintigraphy revealed a focal involvement at the middle-inferior region of left thyroid lobe. Neck magnetic resonance imagination revealed a nodular lesion in size of 22 × 14 mm at the posterior region of left thyroid lobe. Parathyroidectomy guided by intraoperative gamma probe was performed. The lesion was histopathologically consistent with atypical parathyroid adenoma. In the postoperative period, serum calcium and intact parathyroid hormone levels were decreased as levels of 7 mg/dL and 42.6 pg/mL, respectively. We reported an atypical parathyroid adenoma accompanied by severe hypercalcemia and hyperparathyroidism.
Parathyroid hormone-dependent hypercalcemia
Wiener klinische Wochenschrift, 2009
In den vergangenen 15 Jahren wurden große Fortschritte im Verständnis der Pathogenese und der Pathophysiologie sowohl der sporadisch als auch der familiär auftretenden hyperkalzämischen Erkrankungen erzielt. Die vorliegende Arbeit gibt einen kurzen Überblick über die wichtigsten neuen Erkenntnisse bezüglich der sporadischen und der vererbbaren Formen der von der Nebenschilddrüse abhängigen hyperkalzämischen Erkrankungen, wobei der Schwerpunkt der Besprechung bei den familiären Syndromen, wie der MEN Typ I und der MEN Typ II A, dem Hyperparathyreoidismus-Kiefertumor-Syndrom, dem isolierten familiären Hyperparathyreoidismus, der familiären hypokalziurischen Hyperkalzämie und schließlich dem schweren neonatalen primären Hyperparathyreoidismus liegt.
Hypercalcemic Crisis in A Patient with A Huge Mediastinal Atypical Parathyroid Adenoma
AACE Clinical Case Reports, 2018
Objective: To describe a patient who presented with hypercalcemic crisis and severe hyperparathyroidism who had urgent surgery. She was found to have a huge mediastinal atypical parathyroid adenoma (APA). We discuss our case, the difficulty discriminating an APA from parathyroid cancer, and the tools that help differentiate these conditions. Methods: We present the clinical manifestations, laboratory results, radiologic and surgical findings, and management in a patient with hyperparathyroid crisis. Discussion follows. Results: We report a case of a 39-year-old woman who presented with symptoms of severe hypercalcemia. Her intact parathyroid hormone level was found to be markedly elevated, consistent with primary hyperparathyroidism. Imaging revealed an anterior mediastinal mass, suggestive of possible ectopic parathyroid tissue. Urgent surgery and subsequent pathologic study of the excised mass revealed a supernumerary 37.5-g parathyroid gland within the mediastinum surrounded by a rim of thymic tissue. Histologically, the adenoma did not meet the World Health Organization criteria for the diagnosis of parathyroid carcinoma; however, the adenoma had atypical pathologic features given an abnormal mitotic figure. Parafibromin staining was performed and largely negative in the center of the tumor. Germline analysis of the MEN1 and CDC73 genes revealed no pathogenic variants. Her postoperative course was complicated by hypocalcemia but took several days to develop. Conclusion: The distinction between APA and parathyroid carcinoma may be difficult, and parafibromin staining and genetic testing for CDC73 mutations should be considered, as the results have implications for patient follow-up as well as for patients' relatives. (AACE Clinical Case Rep. 2018;4:e224-e227
Clinical and Histopathological Characteristics of Hyperparathyroidism-induced Hypercalcemic Crisis
World Journal of Surgery, 2011
The clinical and pathological characteristics of hyperparathyroidism-induced hypercalcemic crisis (HIHC) are incompletely described. The present study was designed to elucidate the nature and effects of HIHC in patients undergoing parathyroidectomy in our unit. A prospective database of 1,754 consecutive patients with primary hyperparathyroidism (PHPT) who underwent parathyroidectomy from 1991-2009 identified 67 (41 women) patients presenting with HIHC. Hyperparathyroidism-induced hypercalcemic crisis was defined as symptoms and signs of acute calcium intoxication with a concomitant total albumin corrected calcium level>13.5 mg/dl (range: 8.8-10.2 mg/dl). Clinical and pathological characteristics were evaluated. Data are expressed as mean±SEM. Mean age at presentation was 56.7±2.2 years. Twenty-four of 67 patients (35%) required preoperative in-hospital management. Of these, all were treated with saline resuscitation, whereas 20/24 (83%) were treated pharmacologically. Neurocognitive derangements and nephrolithiasis with associated hematuria were the most common presenting symptoms and signs. Preoperative serum calcium and the intact parathyroid hormone level (PTH) were 14.0±0.19 mg/dl and 393±43 pg/ml (reference range: 12-65 pg/ml), respectively. Minimally invasive parathyroidectomy under local cervical block was performed in 28/67 patients (42%); the remainder underwent standard cervical exploration. All patients had postoperative normalization of serum calcium and intact PTH. Hyperparathyroidism-induced hypercalcemic crisis was due to parathyroid carcinoma in 3/67 patients (4.5%), whereas the remainder of patients displayed a single parathyroid adenoma (n=57) or multiglandular hyperplasia (n=7). Histopathological evaluation from HIHC patients revealed a chief cell microcystic pattern in 15/21 (71.4%) of examined parathyroid tumors. Hyperparathyroidism-induced hypercalcemic crisis is most commonly due to a single parathyroid adenoma, often associated with a microcystic histopathological pattern. The condition is optimally managed with saline hydration and urgent parathyroidectomy.
European Journal of Internal Medicine, 2001
Background: Parathyroid hormone (PTH) and parathyroid hormone-related protein (PTH-rP) are two potent hypercalcemic hormones that act on the same targets. Autonomous secretion of the former is involved in primary hyperparathyroidism (PHPT), whereas the latter is responsible for humoral hypercalcemia of malignancy (HHM). Methods: From 250 consecutive, hypercalcemic serum samples sent to our laboratory for assessment of intact PTH, we were able to obtain clinical information, as well as an additional plasma sample for PTH-rP measurement, in 134 patients. At the time of sampling, patients could be classified into seven groups: cancer without known bone metastases (CaNoMeta, n 5 36), cancer with bone metastases (CaMeta, n 5 9), no evidence of cancer (noEvCa, n 5 71), sarcoidosis (Sarc, n 5 3), end-stage renal disease (ESRD, n 5 12), vitamin D overdose (VIT-D, n 5 2), and hyperthyroidism (Thyr, n 5 1). Results: In the CaNoMeta group, 29 / 36 patients had elevated PTH-rP levels, 9 / 36 patients had inappropriately elevated PTH levels, and 5 / 36 had elevated levels of both hormones. In the CaMeta group, three of the nine patients had inappropriately elevated PTH levels, two of them with concomitantly elevated PTH-rP levels. In the NoEvCa group, 63 / 71 patients had an inappropriate elevation of PTH levels and were diagnosed as having PHPT. Four of the 71 patients had elevated levels of both PTH and PTH-rP; three of them were in poor health and died within a short period of time. All of the ESRD patients had very high PTH and normal PTH-rP levels, except for one woman with high PTH-rP and undetectable PTH levels; she died from what later turned out to be a recurrent bladder carcinoma. In the Sarc, Vit-D, and Thyr groups, both PTH and PTH-rP levels were normal. Conclusions: (1) Elevated PTH-rP levels are a common finding in cancer patients without bone metastases. Intact PTH, however, should always be measured in hypercalcemic patients with malignancy because concurrent primary hyperparathyroidism is not rare. (2) Primary hyperparathyroidism accounts for hypercalcemia in 90% of patients without evidence of cancer whose PTH-rP levels may also be found to be elevated in a few cases, even some with surgically demonstrated parathyroid adenoma.
Severe Hypercalcaemia as a Consequence of Parathyroid Crisis - A Case Report
A 36-years old man presenting with the complaint of sudden severe upper abdominal pain, vomiting and polyuria with raised serum creatinine (2.74 mg/dl), serum calcium (19.68 mg/dl) and intact parathyroid hormone (iPTH) (2014.70 pg/ml) level. His ultrasound image of neck region demonstrated hypoechoic mass (12×10 mm) at left inferior parathyroid gland. Parathyroid schintography reported positive for parathyroid adenoma (left lower). He underwent medical management followed by parathyroidectomy. Optimum serum calcium concentration is essential for homeostasis and function of multiple organ systems. Severe hypercalcaemia is rare but life threatening complication of primary hyperparathyroidism (PHPT). In order to prevent mortality, it is necessary to provide immediate appropriate treatment by correcting hypercalcaemia and dehydration.