We describe a case of parathyroid carcinoma which is a rare, yet important cause of primary hyperparathyroidism.
A 22 year old soldier was referred by army medical officer because of abnormal blood test results. He gave a history of weight loss of about 10 kg, increasing shortness of breath and malaise for 1 month prior to presentation. His past medical history was unremarkable, he was a non smoker and did not drink alcohol. He was not on any regular treatment and his family history was not significant. There was nothing of note on general or systemic examination. On admission his bloods were as follows urea 6.7, creatinine 151, Na 136, K 4.7, creatinine clearance 54 ml/hr, bilirubin 22, alk phos 202, ALT 12, Albumin 52, Corrected Calcium 4.07, phosphate 0.75, Hb 141, WCC 8.87 (L 6.47, N 1.78), Platelet 329, ESR 29, urate 0.55, PTH 57.4, 24 hour urinary Calcium 6.0 mmol/d (2.57.5)
ECG sinus rhythm 65/min, QTc 338,
CXR Normal, Bone scan - Bilateral calcified kidneys
USS neck Large almost 1 cm right parathyroid adenoma
Seasta-Mibi parathyroid Loacalised area of marked increased uptake right lower thyroid almost certainly due to parathyroid tumour
CT body and neck Normal
He was referred for parathyroid surgery, and a complete excision of the tumour was achieved. Histology revealed parathyroid carcinoma which was not considered as a diagnosis preoperatively.
3 months post op his serum PTH is still high at 18.9 and his USS and seatamibi reveal an abnormal looking echogenic 13 mm lymph node for which he is going to have PET scanning and an excision biopsy.
Parathyroid carcinoma should be suspected clinically if
-Hypercalcaemia is severe
-Serum PTH levels are very high.
-A cervical mass is palpated in a hypercalcaemic patient
-Hypercalcaemea is associated with unilateral vocal cord paralysis
-Concomitant renal and skeletal disease are observed in a patient with a markedly raised calcium.
One analysis of the literature shows that there is 8% local recurrence after en bloc resection compared with 51% after a standard parathyroidectomy.
06 - 07 Nov 2006
Society for Endocrinology