A 60-year-old male patient who presented with left hip and knee pain was found to be compatible with primary hyperparathyroidism (PTH:2233 pg/ml, calcium: 15.7 mg/dl, phosphorus: 2.9 mg/dl creatinin:1.99 mg/dl, 25-OH-D:9.7 μg/l, ALP:532 mU/ml). Bone grafts of the patient showed multiple lytic lesions in the pelvis, cranium and long-bones. Neck ultrasonography showed hypoechoic solid nodule with cystic areas, 2×2 cm with size in the left thyroid gland inferior region and delayed wash-out was detected by the parathyroid scintigraphy. Bone scintigraphy was suspicious in terms of metastasis. Left hemi thyroidectomy and left inferior parathyroidectomy was performed. In thorax lytic lesions compatible with multiple metastases in bone structures were observed. Thoracal and lumbar vertebral MR imaging also showed lesions compatible with metastasis. Histopathological examination revealed parathyroid carcinoma with invasion to the thyroid gland.
Primer hyperthyroidism has been increasing in recent years as a laboratory diagnosis the contribution of asymptomatic cases has increased. Frequent routine examinations have also led to the early recognition of the disease, and osteitis fibrosa cystica and bone lesions such as brown tumor, which are among the complications of primary hyperparathyroidism, are increasingly rare. Primer Hyperparathyroidism is often associated with solitary parathyroid adenoma, hyperplasia or multiple adenomas, mostly seen with the genetic syndromes. Parathyroid carcinoma is very rare and is recognized only by the presence of metastases or histopathologically significant invasion findings, such as those present in our case. Clinically, incompatibility in tumor size and serum PTH levels, extremely high PTH levels may be a sign of parathyroid carcinoma. Apart from this, common bony lesions which are rarely seen in primary hyperparathyroidia due to early diagnosis and noisy clinical picture can be considered as malignancy findings as it is in our patient. Therefore, in patients with widespread pain and common bony lesions, the patient should be carefully examined for parathyroid carcinoma and an appropriate approach should be sought.
20 - 23 May 2017
European Society of Endocrinology