Left parathyroid carcinoma with secondary hyperparathyroidism: a case report

Abstract

Background Parathyroid carcinoma is a rare disease with a frequency of 0.005% of all malignancies [1, 2]. Various aspects of its pathogenesis, diagnosis, and treatment remain poorly understood. Furthermore, cases with secondary hyperparathyroidism are fewer. In this case report, we describe a case of left parathyroid carcinoma with secondary hyperparathyroidism. Case presentation The patient was a 54-year-old woman who had been on hemodialysis since the age of 40 years. At 53 years of age, her calcium levels were high, and she was diagnosed with drug-resistant secondary hyperparathyroidism and was referred to our hospital for surgical treatment. Blood tests revealed calcium levels of 11.4 mg/dL and intact parathyroid hormone (PTH) levels of 1007 pg/mL. Neck ultrasonography revealed a 22-mm large round hypoechoic mass, partially indistinct margins, and D/W ratio > 1 at the left thyroid lobe. Computed tomography scans revealed a 20-mm nodule at the left thyroid lobe. No enlarged lymph nodes or distant metastases were noted. 99mTc-hexakis-2-methoxyisobutylisonitrile scintigraphy revealed an accumulation at the superior pole of the left thyroid lobe. Laryngeal endoscopy revealed paralysis of the left vocal cord, signifying recurrent nerve palsy due to parathyroid carcinoma. Based on these results, a diagnosis of secondary hyperparathyroidism and suspected left parathyroid carcinoma was made, and the patient underwent surgery. Pathology results revealed hyperplasia in the right upper and lower parathyroid glands. The left upper parathyroid gland showed capsular and venous invasion, and the diagnosis was left parathyroid carcinoma. At 4 months post-surgery, calcium levels improved to 8.7 mg/dL and intact PTH levels to 20 pg/mL, with no signs of recurrence. Conclusions We report a case of left parathyroid carcinoma associated with secondary hyperparathyroidism. Concomitant secondary hyperparathyroidism may cause mild hypercalcemia compared to parathyroid carcinoma alone due to the added modification of dialysis. Although our patient also presented with mild hypercalcemia, a D/W ratio > 1 on preoperative echocardiography and presence of recurrent nerve palsy on laryngoscopy led to the suspicion and treatment of parathyroid carcinoma preoperatively.

Coincidence or Causality: Parathyroid Carcinoma in Chronic Kidney Disease—Case Report and Literature Review

“…Of all ESRD patients undergoing PTx, nodular hyperplasia is the most common histopathological result reported in the literature, followed by diffuse hyperplasia, while malignancy is found only in an anecdotic number of cases [ 14 , 57 ]. Preoperative higher MIBI uptake is, generally, associated with a considerably higher prevalence of nodular hyperplasia, higher gland weight, and greater cell proliferation [ 57 , 58 ].…”

“…Preoperative higher MIBI uptake is, generally, associated with a considerably higher prevalence of nodular hyperplasia, higher gland weight, and greater cell proliferation [ 57 , 58 ]. Yokoyama et al [ 14 ] identified 37 PC cases in SHPT reported until 2022. Up to the writing of this manuscript, five more cases have been published ( Table 3 ).…”

“…It often becomes resistant to available medical treatments, raising the need for parathyroidectomy (PTx) [ 10 , 11 , 12 ]. PC is seldom diagnosed after PTx in SHPT, with only 42 cases reported up to the writing of this manuscript [ 13 , 14 , 15 ], while the mechanism of parathyroid tumorigenesis is not fully understood [ 8 , 9 , 10 , 16 , 17 ]. Moreover, features that help identify PC in PHPT mimic the natural changes undergone by the parathyroid glands in SHPT (large dimensions, very high parathormone (PTH), high 99mTc-methoxyisobuthylisonitrile (99mTc-MIBI) scintigraphy uptake on scintigraphy, and low expression of vitamin D or calcium-sensing receptor) [ 11 , 12 , 16 , 18 , 19 ].…”

“…The management of these patients after diagnosis remains a dilemma, as reintervention poses the risk of parathyromatosis [ 20 ]. Nevertheless, reported outcomes differ significantly, even in the absence of “gold standard” surgery [ 14 , 15 ].…”

Recurrence hyperparathyroidism caused by synchronous parathyroid carcinoma and parathyromatosis in a patient with long-term hemodialysis

“…An increased incidence of parathyroid carcinoma has been associated with ESRD [ 19 ]. According to the literature, the mean age is 55 years, with approximately equal sex distribution [ 9 ]. The biochemical and clinical characteristics are characterized by markedly elevated serum calcium, PHT and target-organ damage [ 20 ].…”