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Ezeani C, Echefu G, Stowe I, Kumbala D, Murad S. A case report of mediastinal parathyroid carcinoma in a chronic kidney disease patient: Addressing management conundrum. SAGE Open Med Case Rep 2024; 12:2050313X241245919. [PMID: 38628858 PMCID: PMC11020733 DOI: 10.1177/2050313x241245919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 03/21/2024] [Indexed: 04/19/2024] Open
Abstract
Parathyroid carcinoma is a rare malignancy; and it is rarer to find one located in an ectopic location. Ectopic parathyroid glands are a reported cause of failed primary surgery for hyperparathyroidism. We report here a 73-year-old male who previously had parathyroidectomy for primary hyperparathyroidism but then had recurrence of his symptoms with a diagnosis of a mediastinal parathyroid carcinoma on further evaluation. This presentation of complicated mediastinal parathyroid carcinoma posed significant diagnostic and management challenges due to comorbid stage IV chronic kidney disease (CKD). Secondly, due to the same comorbid condition, a more aggressive calcimimetic regimen could not be undertaken due to the risk of renal dysfunction with potential progression to dialysis status. Thirdly, he was a high-risk surgical candidate due to significant cardiovascular risks. Ideally, open surgical intervention would be recommended but due to the associated risks, he was managed with robotic-assisted thoracoscopic surgery. He subsequently developed hypocalcemia which normalized with supplemental calcium at follow-up.
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Affiliation(s)
- Chukwunonso Ezeani
- Department of Internal Medicine, Baton Rouge General Medical Center, LA, USA
| | - Gift Echefu
- Department of Internal Medicine, Baton Rouge General Medical Center, LA, USA
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, LA, USA
| | - Damodar Kumbala
- Vascular Clinic of Baton Rouge, LA, USA
- Renal Associates of Baton Rouge, Baton Rouge, LA, USA
| | - Shatha Murad
- Department of Endocrinology, Baton Rouge Clinic, LA, USA
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Cetani F, Pardi E, Torregrossa L, Borsari S, Pierotti L, Dinoi E, Marcocci C. Approach to the Patient With Parathyroid Carcinoma. J Clin Endocrinol Metab 2023; 109:256-268. [PMID: 37531615 DOI: 10.1210/clinem/dgad455] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 06/27/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023]
Abstract
Parathyroid carcinoma (PC) is usually associated with severe symptomatic primary hyperparathyroidism (PHPT) and accounts for less than 1% of all cases of PHPT and approximately 0.005% of all cancers. PC most commonly occurs as a sporadic disease and somatic CDC73 mutations can be detected in up to 80% of cases. Approximately 30% of patients harbor a germline mutation of the CDC73 gene. Preoperative diagnosis of PC is difficult because no disease-specific markers are available, and PC should be suspected in patients with severe hypercalcemia and end-organ complications. The diagnosis is based on the evidence of invasive tumor growth at histology and/or metastases. En bloc resection of the tumor, together with the ipsilateral thyroid lobe and adjacent structures, should be performed by an experienced surgeon when PC is suspected. This surgical approach reduces the risk of recurrence and metastasis and offers the highest chance of cure. Nonetheless, PC has a recurrence rate of 40% to 60% and, if feasible, multiple surgical procedures should be performed. When surgery is no longer an option, medical treatment is aimed to reduce hypercalcemia and target organ complications. Targeted agents have been effectively used in a few cases. We describe herein a patient with severe PHPT due to PC and provide a systematic diagnostic and treatment approach. A thorough review of the medical history, a typical clinical and biochemical phenotype and, in some cases, the revision of the histological examination provide the clues for the diagnosis of PC.
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Affiliation(s)
- Filomena Cetani
- Unit of Endocrinology, University Hospital of Pisa, 56124 Pisa, Italy
| | - Elena Pardi
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Liborio Torregrossa
- Department of Surgical, Medical, Molecular Pathology and Clinical Area, University of Pisa, 56126 Pisa, Italy
| | - Simona Borsari
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Laura Pierotti
- Unit of Endocrinology, University Hospital of Pisa, 56124 Pisa, Italy
| | - Elisa Dinoi
- Unit of Endocrinology, University Hospital of Pisa, 56124 Pisa, Italy
| | - Claudio Marcocci
- Unit of Endocrinology, University Hospital of Pisa, 56124 Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
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Jacquet-Francillon N, Prevot N. Brown tumors in nuclear medicine: a systematic review. Ann Nucl Med 2023; 37:255-270. [PMID: 36933117 DOI: 10.1007/s12149-023-01832-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/27/2023] [Indexed: 03/19/2023]
Abstract
Brown tumors (BT) are abnormal bone-repair processes and a consequence of hyperparathyroidism. The diagnosis of these lytic lesions in nuclear medicine, while a challenge, is not so rare, because functional imaging is used both in the management of cancer and hyperparathyroidism. The main objective of this review is to summarize the knowledge and the evidence concerning BT and the different imaging modalities in nuclear medicine. A systematic review was performed in Embase, PubMed and Google Scholar from 2005 to 2022. We included articles describing BT in the following imaging modalities: [18F]-fluorodeoxyglucose PET/CT, [18F]-fluorocholine or [11C]-fluorocholine PET/CT, [99mTc]-Sestamibi scintigraphy, bone scan, [18F]-sodium fluoride PET/CT, [68Ga]-FAPI PET/CT; [68Ga]-DOTATATE PET/CT; [11C]-methionine PET/CT. For each modality, appearance, avidity for radiotracer, available quantitative parameters and imaging evolution after parathyroidectomy were collected and analyzed. Fifty-two articles were included for a total of 392 BT lesions. If the diagnosis of BT is evoked on a known lesion, performing a [18F]-fluorocholine PET/CT imaging seems the most appropriate. In [18F]-fluorodeoxyglucose, [18F]-fluorocholine, [18F]-sodium fluoride PET/CT and bone scan, BT can mimic metastatic disease. BT uptakes appear reversible after parathyroidectomy, with a more or less rapid decrease depending on the imaging modality used.
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Affiliation(s)
- Nicolas Jacquet-Francillon
- Nuclear Medicine Department, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Hopital Lyon Sud, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.
| | - Nathalie Prevot
- Department of Nuclear Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France.,Univ Jean Monnet, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France
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Tsai WH, Zeng YH, Lee CC, Tsai MC. Mortality factors in recurrent parathyroid cancer: a pooled analysis. J Bone Miner Metab 2022; 40:508-517. [PMID: 35184206 DOI: 10.1007/s00774-021-01305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Parathyroid cancer is a rare disease with high recurrence rate. The prognostic factors for recurrent parathyroid cancer are yet to be ascertained. We aimed to establish the association between recurrent parathyroid cancer and previously reported prognostic factors. MATERIALS AND METHODS We conducted a PubMed search using the keywords 'parathyroid cancer', 'parathyroid neoplasm', and 'hypercalcemia' during 1966-2019 and included 3272 articles. We focused on 73 patients with recurrent parathyroid cancer from 55 studies. We conducted a survival analysis using the Cox proportional hazards model with 95% confidence interval. RESULTS For the 73 patients included in the analysis, the mean age (± standard deviation) was 44 ± 13.2 years, wherein 36 patients were women (49.3%). During the 5236 person-months at risk (mean follow-up 71.7 months, range 3-264), 38 patients died. The incidence of local recurrence, lymph-node metastasis, lung metastasis, and bone metastasis were 60.3, 12.3, 56.2, and 24.7, respectively. Bone metastasis, disease-free interval < 1 year, and total surgeries < 3 were significant prognostic factors in univariate analysis (log-rank test P = 0.0063, P = 0.0006, and P = 0.0056, respectively). In the multivariate-adjusted analysis, the mortality risk was significantly increased in patients with bone metastasis with a hazard ratio (HR) of 4.83 (95% CI 1.16-20.2; P = 0.03), disease-free interval <=1 year of 5.92 (95% CI 1.85-18.99; P = 0.003), and total surgeries <3 of 11.29 (95% CI 2.82-45.22; P = 0.001), considering these as possible predictive prognostic factors. CONCLUSION Bone metastasis, duration of disease-free interval, and total number of surgeries predict survival in recurrent parathyroid cancer.
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Affiliation(s)
- Wen-Hsuan Tsai
- Division of Endocrinology and Metabolism, Department of Endocrinology, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist, Taipei City, 104, Taiwan (ROC)
| | - Yi-Hong Zeng
- Division of Endocrinology and Metabolism, Department of Endocrinology, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist, Taipei City, 104, Taiwan (ROC)
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan (ROC)
| | - Chun-Chuan Lee
- Division of Endocrinology and Metabolism, Department of Endocrinology, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist, Taipei City, 104, Taiwan (ROC)
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan (ROC)
| | - Ming-Chieh Tsai
- Division of Endocrinology and Metabolism, Department of Endocrinology, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist, Taipei City, 104, Taiwan (ROC).
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan (ROC).
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Abstract
ABSTRACT A 50-year-old man presented with right chest pain and persistent increased parathyroid hormone after parathyroidectomy for parathyroid carcinoma. 68Ga-DOTATATE PET/CT and 18F-FDG PET/CT were performed consecutively for restaging to determine subsequent treatment strategy. An osteolytic lesion on the right sixth rib showed increased uptake on both 68Ga-DOTATATE and 18F-FDG PET/CT. Subsequent biopsy confirmed it to be a brown tumor.
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Affiliation(s)
- Xilan Yao
- From the Department of Nuclear Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Clinical Presentation, Treatment, and Outcome of Parathyroid Carcinoma: Results of the NEKAR Retrospective International Multicenter Study. Ann Surg 2020; 275:e479-e487. [PMID: 32649472 DOI: 10.1097/sla.0000000000004144] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In this retrospective cohort study, we describe the clinical presentation and workup of parathyroid carcinoma (PC) and determine its clinical prognostic parameters. Primary outcome was recurrence free survival. SUMMARY BACKGROUND DATA PC is an orphan malignancy for which diagnostic workup and treatment is not established. METHODS Eighty-three patients were diagnosed with PC between 1986 and 2018. Disease-specific and recurrence-free survivals were estimated with the Kaplan-Meier method. Risk factors for recurrence were identified by binary logistic regression with adjustment for age and sex. Thirty-nine tumors underwent central histopathological review. RESULTS Renal (39.8%), gastrointestinal (24.1%), bone (22.9%), and psychiatric (19.3%) symptoms were the most common symptoms. Surgical treatment was heterogeneous [parathyroidectomy [PTx)] alone: 22.9%; PTx and hemithyroidectomy: 24.1%; en bloc resection 15.7%; others 37.3%] and complications of surgery were frequent (recurrent laryngeal nerve palsy 25.3%; hypoparathyroidism 6%). Recurrence of PC was observed in 32 of 83 cases. In univariate analysis, rate of recurrence was reduced when extended initial surgery had been performed (P = 0.04). In multivariate analysis low T status [odds ratio (OR) = 2.65, 95% confidence interval (CI) 1.02-6.88, P = 0.045], N0 stage at initial diagnosis (OR = 6.32, 95% CI 1.33-30.01, P = 0.02), Ki-67 <10% (OR = 14.07, 95% CI 2.09-94.9, P = 0.007), and postoperative biochemical remission (OR = 0.023, 95% CI 0.001-0.52, P = 0.018) were beneficial prognostic parameters for recurrence-free survival. CONCLUSION Despite a favorable overall prognosis, PC shows high rates of recurrence leading to repeated surgery and postoperative recurrent laryngeal nerve palsy and hypoparathyroidism. In view of the reduced recurrence rate in cases of extended surgery, ipsilateral completion surgery may be considered when PC is confirmed.
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Fernandes JMP, Paiva C, Correia R, Polónia J, Moreira da Costa A. Parathyroid carcinoma: From a case report to a review of the literature. Int J Surg Case Rep 2017; 42:214-217. [PMID: 29353223 PMCID: PMC5985244 DOI: 10.1016/j.ijscr.2017.11.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/14/2017] [Accepted: 11/16/2017] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Parathyroid carcinoma is a rare endocrine malignancy. The reported incidence is from 0.5 to 5% of primary hyperparathyroidism cases in various series. Consideration of parathyroid carcinoma in the differential diagnosis of hypercalcaemic disorders is important because the morbidity and mortality are substantial and the best prognosis is associated with early recognition and surgical resection. PRESENTATION OF CASE We report a case of parathyroid carcinoma occurring in a 60-year-old woman who presented to our institution with persistent hyperparathyroidism and hypercalcemia 3 years after being submitted to one gland parathyroidectomy in another hospital. DISCUSSION AND CONCLUSION A review of the related literature follows.
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Affiliation(s)
| | - Claudia Paiva
- Serviço de Cirurgia Geral, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal
| | - Raquel Correia
- Serviço de Cirurgia Geral, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal
| | - José Polónia
- Serviço de Cirurgia Geral, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal
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Abstract
A 53-year-old man complained of aggravated left hip pain of more than 2 months. Whole-body (18)F-FDG PET/CT revealed only 1 hypermetabolic lesion in the left ilium. Histopathologic examination of the lesion suggested metastatic disease. Blood tests documented mildly elevated blood calcium and parathyroid hormone. Subsequent neck ultrasonography, contrast-enhanced CT, and dual-phase scintigraphy with (99m)Tc-MIBI showed a right parathyroid tumor, which was confirmed to be a parathyroid carcinoma postoperatively. We report a case of parathyroid carcinoma rarely encountered with a FDG-negative primary but a FDG-positive metastasis on PET/CT images.
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Evangelista L, Sorgato N, Torresan F, Boschin IM, Pennelli G, Saladini G, Piotto A, Rubello D, Pelizzo MR. FDG-PET/CT and parathyroid carcinoma: Review of literature and illustrative case series. World J Clin Oncol 2011; 2:348-54. [PMID: 22022662 PMCID: PMC3191327 DOI: 10.5306/wjco.v2.i10.348] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 09/14/2011] [Accepted: 09/22/2011] [Indexed: 02/06/2023] Open
Abstract
Parathyroid cancer is an uncommon malignant cancer and is associated with a poor prognosis. The staging of parathyroid cancer represents an important issue both at initial diagnosis and after surgery and medical treatment. The role of positron emission tomography/computed tomography (PET/CT) with 18F-Fluorodeoxyglucose (18F-FDG) as an imaging tool in parathyroid cancer is not clearly reported in the literature, although its impact in other cancers is well-defined. The aim of the following illustrative clinical cases is to highlight the impact of PET/CT in the management of different phases of parathyroid cancer. We describe five patients with parathyroid malignant lesions, who underwent FDG PET/CT at initial staging, restaging and post-surgery evaluation. In each patient we report the value of PET/CT comparing its findings with other common imaging modalities (e.g., CT, planar scintigraphy with 99mTc-sestamibi, magnetic resonance imaging) thus determining the complementary benefit of FDG PET/CT in parathyroid carcinoma. We hope to provide an insight into the potential role of PET/CT in assessing the extent of disease and response to treatment which are the general principles used to correctly evaluate disease status.
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Affiliation(s)
- Laura Evangelista
- Laura Evangelista, Giorgio Saladini, Radiotherapy and Nuclear Medicine Unit, Istituto Oncologico Veneto (IOV - IRCCS), Padova 35128, Italy
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Abstract
OBJECTIVE To review the current knowledge pertaining to the etiology, molecular pathogenesis, and management of parathyroid carcinoma, a rare presentation of primary hyperparathyroidism. METHODS The existing MEDLINE English-language literature was reviewed using the search terms "parathyroid" and "carcinoma" or "cancer." RESULTS Parathyroid cancer is a rare endocrine tumor accounting for a small proportion of cases of primary hyperparathyroidism. Recent database studies indicate increasing incidence rates. Its etiology is unknown, although numerous molecular alterations have been described, and the tumors also occur in association with germline mutations in the CDC73 gene. Most affected patients present with severe hypercalcemia; however, the diagnosis can be challenging. Complete surgical resection remains the mainstay of treatment and provides the best chance of cure, although data from small series suggest that external beam radiation may also reduce the high recurrence rates. No effective chemotherapy regimens are currently available. A significant number of patients develop recurrent disease and need additional procedures; however, long-term survival is possible with palliative surgery. Medical management of chronic and debilitating hypercalcemia with calcimimetics is often necessary and is an important adjunct in patients with recurrent and metastatic disease. CONCLUSIONS Further elucidation of the molecular pathogenesis of parathyroid carcinomas will enhance our understanding of etiology and behavior of this uncommon entity. Future research must be directed at identifying more effective therapies for this condition.
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Affiliation(s)
- Sandy H Fang
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA
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Givi B, Shah JP. Parathyroid carcinoma. Clin Oncol (R Coll Radiol) 2010; 22:498-507. [PMID: 20510594 DOI: 10.1016/j.clon.2010.04.007] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 04/27/2010] [Indexed: 11/26/2022]
Abstract
Parathyroid carcinoma is a rare endocrine malignancy. The reported incidence is from 0.5 to 5% of primary hyperparathyroidism cases in various series. The cause is unknown, but clinical correlations with different genetic syndromes exist. Mutations in the HPRT2 gene seem to play a significant role in the pathogenesis of this disease. Men and women are equally affected, usually in the fourth or fifth decade of life. Most patients will present with signs and symptoms of hypercalcaemia. Cases of non-functioning carcinoma are exceedingly rare. Surgical resection is the most effective method of treatment and palliation. A significant proportion of patients will experience recurrence, and will need further surgical and, eventually, medical management of hypercalcaemia. The disease is progressive but slow growing. Most patients will require multiple operations to resect recurrent disease. The main cause of morbidity and mortality is the sequela of uncontrolled chronic hypercalcaemia rather than tumour burden. The current paper will review the epidemiology, pathogenesis, clinical presentation and diagnostic work-up of this disease. Surgical management in different scenarios is reviewed in detail, followed by other types of treatment and management of incurable disease.
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Affiliation(s)
- B Givi
- Head and Neck Service, Department of Surgery, 1275 York Ave, Memorial Sloan-Kettering Cancer Center, New York 10065, USA
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