Parathyroid Cancer—A Rare Finding during Parathyroidectomy in High Volume Surgery Centre

Abstract

Background and Objectives: Parathyroid cancer is a very rare endocrine tumor, especially in patients with secondary hyperparathyroidism due to end stage renal disease failure. This pathology is difficult to diagnose preoperatively because it has nonspecific clinical manifestations and paraclinical aspects. Our study of the literature identified 34 reported cases of parathyroid carcinoma over the last 40 years in patients undergoing dialysis. We present our experience as illustrative of the features of clinical presentation and histopathological findings of parathyroid carcinoma and assess its management considering the recent relevant literature. Materials and Methods: From January 2012 to November 2022, 650 patients with secondary hyperparathyroidism undergoing dialysis were treated at our academic Department of General Surgery and only two cases of parathyroid carcinoma were diagnosed on histopathological examination. Results: All patients presented with symptomatic hypercalcemia, with no clinical or imaging suspicion of malignant disease and were surgically treated by total parathyroidectomy. Histopathological examination revealed morphologic aspects of parathyroid carcinoma in two cases and immunostaining of Ki-67 was performed for diagnostic confirmation. Postoperative follow-up showed no signs of recurrence and no oncological adjuvant treatment or surgical reinterventions were needed. Conclusions: Parathyroid neoplasia is a particularly rare disease, that remains a challenge when it comes to diagnosis and proper management. Surgical approach is the only valid treatment to remove the malignant tissue and thus improve the patient’s prognosis. Medical and oncologic treatment may be beneficial to control hypercalcemia in case of tumor recurrence.

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

“…Up to the writing of this manuscript, five more cases have been published ( Table 3 ). Around 3% of all PC cases were identified in dialysis patients, despite the significantly higher PTH concentrations in ESRD-related SHPT [ 15 , 43 ]. Nevertheless, there may be some degree of superposition between SHPT and PHPT with renal involvement, as renal involvement was reported in 32% to 84% of malignant parathyroid tumors [ 3 , 59 ].…”

“…Classically, very high calcium levels above 14–15 mg/dL accompanied by PTH levels more than five times above the upper normal limit, high ALP > 285 IU/L, significantly decreased 1/3 radius BMD or gland diameter > 3 cm should raise the suspicion of PC in PHPT patients [ 1 , 15 , 46 , 63 ]. However, these features do not apply to SHPT, where nodular hyperplasia can reach significant enlargement, the serum levels of ALP and PTH are highly elevated, and 1/3 radius BMD is compromised.…”

“…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 ].…”

Left parathyroid carcinoma with secondary hyperparathyroidism: a case report

“…Only 37 cases of parathyroid carcinoma associated with secondary hyperparathyroidism have been reported in the English literature since Berland et al’s report in 1982 [ 13 ]. The 37 cases are summarized in Table 3 [ 13 – 46 ]. The mean age of the patients was 50.5 years.…”