Prolonged remission of hypercalcaemia due to parathyroid carcinoma with pamidronate

Mortality factors in recurrent parathyroid cancer: a pooled analysis

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.

Cinacalcet hydrochloride relieves hypercalcemia in Japanese patients with parathyroid cancer and intractable primary hyperparathyroidism

Pharmacological treatment of hypercalcemia is essential for patients with parathyroid carcinoma and intractable primary hyperparathyroidism (PHPT). Use of the calcimimetic cinacalcet hydrochloride (cinacalcet) is an option to treat such patients. We investigated the efficacy and safety of cinacalcet in Japanese patients with parathyroid carcinoma and intractable PHPT. Five Japanese patients with parathyroid carcinoma and two with intractable PHPT were enrolled in an open-label, single-arm study consisting of titration and maintenance phases. Cinacalcet doses were titrated until the albumin-corrected serum calcium concentration decreased to 10.0 mg/dL or less or until dose escalation was considered not necessary or feasible. Serum calcium concentration at the baseline was 12.1 ± 1.3 mg/dL (mean ± standard deviation; range 10.4-14.6 mg/dL) and decreased to 10.1 ± 1.6 mg/dL (range 8.6-13.3 mg/dL) at the end of the titration phase with cinacalcet at a dosage of up to 75 mg three times a day. At the end of the titration phase, at least a 1 mg/dL reduction in serum calcium concentration from the baseline was observed in five patients (three with carcinoma and two with PHPT), and it decreased to the normocalcemic range in five patients (three with carcinoma and two with PHPT). Common adverse events were nausea and vomiting. One patient discontinued participation in the study because of an adverse event, liver disorder. Cinacalcet effectively relieved hypercalcemia in 60% of the Japanese patients with parathyroid carcinoma and might be effective in those with intractable PHPT. The drug might be tolerable and safe at a dosage of at most 75 mg three times a day.

Denosumab for management of parathyroid carcinoma-mediated hypercalcemia

CONTEXT

Most of the morbidity and mortality from parathyroid cancer is due to PTH-mediated hypercalcemia. Classically, management mainly consists of surgical resection, chemotherapy, and alleviation of hypercalcemia using bisphosphonates and calcium receptor agonists. The use of denosumab in the treatment of parathyroid cancer-mediated hypercalcemia has not been reported.

OBJECTIVE

The aim of this report is to describe the effect of denosumab on parathyroid cancer-induced hypercalcemia. SUBJECT, MEASURES, AND RESULT: The patient is a 39-year-old man with metastatic parathyroid cancer who presented at age 35. His calcium levels initially responded to surgery, bisphosphonates, calcium receptor agonist, and chemotherapy (dacarbazine). However, his disease progressed, and his hypercalcemia became refractory to these measures in the setting of rising PTH levels. The addition of denosumab, a humanized monoclonal antibody inhibiting receptor activator of nuclear factor κB ligand resulted in successful management of his hypercalcemia for an additional 16 months.

CONCLUSIONS

Denosumab can be effective in the treatment of refractory hypercalcemia in parathyroid cancer. It may also be of potential use in settings of benign hyperparathyroid-related hypercalcemia such as parathyromatosis, where hypercalcemia is not amenable to surgery or medical therapy with bisphosphonates and calcium receptor agonists.

Parathyroid carcinoma

Parathyroid carcinoma is a rare tumor that is prone to recurrence and poor local-regional control. Despite advances in technologies that have shown promise for accurate diagnosis, the mainstay of initial diagnosis remains pathologic analysis and clinical assessment. A surgeon's intraoperative analysis is important in managing patients with parathyroid carcinoma. If parathyroid carcinoma is suspected intraoperatively, a more aggressive surgical strategy should be implemented. This article presents a case series and summary of the existing parathyroid carcinoma literature.

Severe Hyperparathyroidism Versus Parathyroid Carcinoma: A clinical dilemma

No clinical or laboratory data allow a preoperative diagnosis of parathyroid carcinoma and only occasionally does a definitive finding differentiate an adenoma from a carcinoma. We present a case of primary hyperparathyroidism presenting with severe elevation of parathyroid hormone and serum calcium as well as complications. We go on to discuss the case in the light of a literature review. The severity of the elevation of the parathyroid hormone, other biochemical alterations, the presence of skeletal and renal complications and of a neck mass should alert the clinician to a possible parathyroid carcinoma. Radical surgery is the only effective therapy for parathyroid carcinoma, and should always be performed if a preoperative suspicion is entertained.

Clinical presentation, staging and long-term evolution of parathyroid cancer

BACKGROUND

Parathyroid cancer is rare and often fatal. This review provides an in-depth analysis of 330 clinical cases reported in detail. These data are used to inform a proposal for a hitherto lacking TNM staging system.

MATERIALS AND METHODS

All case reports or series with sufficient case details of parathyroid cancer were identified from PubMed, and data were analyzed using SPSS.

RESULTS

Of 330 patients, 117 (35%) died of disease and 207 (63%) experienced recurrence in a total of 2007 follow-up years and a mean length of follow-up of 6.1 years. Histopathology findings rather than biochemical or clinical features predict outcome. In univariate analysis, survival and recurrence rates are significantly influenced by gender (male relative risk [RR] 1.7, 95% confidence interval [95% CI] 1.0-2.7, P < .01), and presence of vascular invasion (RR 4.3, 95% CI 1.1-17.7, P < .01), or lymph node metastases (RR 6.2, 95 %CI 0.9-42.9, P < .001). Failure to perform oncological surgery carries a high risk for recurrence and death (local versus en bloc resection RR 2.0, CI 1.2-3.2, P < .01) as for redo surgery. Staging by a novel anatomy-based TNM system identifies significant outcome variation as to recurrence and death. Separation of patients into low and high risk identifies a 3.5-7.0 fold higher risk of recurrence and death (P < .01) for the high-risk group. Distant metastases predominantly target mediastinum and lung.

CONCLUSION

Understaging and undertreatment are shown to contribute to high recurrence rates and death toll. To improve outcome, en bloc resection including central lymph node dissection should be the minimal surgical approach in any patient with suspected parathyroid cancer.

Cinacalcet hydrochloride reduces the serum calcium concentration in inoperable parathyroid carcinoma

BACKGROUND

Management of inoperable parathyroid carcinoma presents a challenge because until recently, effective medical therapy was not available. Morbidity and mortality result primarily from severe hypercalcemia. We assessed the ability of the calcimimetic cinacalcet HCl to reduce serum calcium in patients with parathyroid carcinoma as well as its effect on PTH concentrations, bone turnover markers, safety, and health-related quality of life variables.

METHODS

Twenty-nine patients with parathyroid carcinoma were enrolled in this open-label, single-arm study consisting of titration and maintenance phases. Cinacalcet doses were titrated (30 mg twice daily to 90 mg four times daily) for 16 wk or until serum calcium was no more than 10.0 mg/dl. The study endpoint was the proportion of patients with at least a 1 mg/dl reduction in serum calcium at the end of the titration phase (responders).

RESULTS

Mean (+/- se) serum calcium (14.1 +/- 0.4 mg/dl) and PTH (697 +/- 94 pg/ml) were markedly elevated at baseline. At the end of the titration period, serum calcium was reduced by at least 1 mg/dl in 62% of patients (mean decline to 12.4 +/- 0.5 mg/dl). In the 18 responders, serum calcium fell from 15.0 +/- 0.5 to 11.2 +/- 0.3 mg/dl (P < 0.001). The greatest reductions in serum calcium were observed in patients with highest baseline calcium levels. PTH levels decreased, but not significantly, to 635 +/- 73 pg/ml (-4.6%). Adverse events included nausea, vomiting, headache, and fracture.

CONCLUSIONS

Cinacalcet effectively reduces hypercalcemia in approximately two thirds of patients with inoperable parathyroid carcinoma and may represent an important new treatment option for these patients.

Parathyroid carcinoma

PURPOSE OF REVIEW

This article reviews current knowledge on the etiology, diagnosis and treatment of parathyroid carcinoma.

RECENT FINDINGS

Due to its rarity, research on the molecular etiology and treatment of parathyroid carcinoma has been slow. Mutations of the tumor suppressor gene, HRPT2, and resultant loss of expression of its gene product have been found in the majority of parathyroid cancers studied. Recent advances in the field have identified regions on several chromosomes that demonstrate loss of heterozygosity more commonly in parathyroid carcinoma than in benign parathyroid lesions. This has provided clues to the location and identity of additional tumor suppressor genes associated with the development of this cancer.

SUMMARY

Parathyroid carcinoma is an extremely rare cause of primary hyperparathyroidism, accounting for fewer than 1% of cases. The etiology of parathyroid cancer is largely unknown. Associations have been made with several inherited syndromes and with specific genetic lesions. Little is known about the most appropriate management of this disease. En bloc resection at the time of initial surgery appears to provide the best chance of cure. Anecdotal experience with adjuvant chemotherapy has shown a modest and short-lived effect. External beam radiation following surgical resection, however, may increase long-term survival compared with surgery alone. Bisphosphonates and a new class of drugs known as calcimimetics have been used effectively in some patients to control the symptoms of severe hypercalcemia in a palliative setting.

Parathyroid carcinoma

Parathyroid carcinoma is a relatively rare tumor that is prone to recurrence and poor loco-regional control. This article discusses the epidemiology, presentation, operative findings, pathology,management, genetics, outcome, and other aspects of parathyroid carcinoma.

Carcinoma de paratiróide: características clínicas e anátomo-patológicas de cinco casos

O carcinoma de paratiróide é uma entidade rara, havendo cerca de 535 casos descritos na literatura. Neste trabalho, revisamos a nossa casuística de 5 pacientes com carcinoma de paratiróide avaliados no período de 1983 a 1998 no serviço de Doenças Ósteo-Metabólicas da Universidade Federal de São Paulo, analisando critérios diagnósticos, conduta terapêutica e a evolução destes pacientes e comparando os nossos dados com os achados de literatura. Entre os nossos pacientes, 4 eram do sexo feminino e 1 do sexo masculino, com mediana ao diagnóstico de 52 anos de idade, variando de 10 a 77 anos. As queixas iniciais incluíam presença de dores ósseas acompanhada de perda de peso em 4 pacientes, presença de fratura não traumática em 3 pacientes e traumática em 2 e clínica de nefrolitíase em 1 paciente. Todos apresentavam nódulo palpável em região cervical, níveis de cálcio total bastante elevados com média(±DP) de 14,9±1,7mg/dL. PTH também se encontrava muito elevado, refletindo a magnitude da severidade da doença. Todos foram submetidos à exploração cirúrgica cervical com retirada da massa tumoral, que foi coincidente com o achado palpatório de nódulo cervical. O exame anátomo-patológico revelou o diagnóstico de carcinoma de paratiróide em todos estes casos. No seguimento, 2 pacientes apresentaram recidiva tumoral e evoluíram para óbito por complicações do hiperparatiroidismo. Os outros 3 casos encontram-se em acompanhamento ambulatorial no nosso hospital, sem evidências até o momento de recidiva tumoral.

Parathyroid cancer: biology and management

A review of all reports in the literature of parathyroid carcinoma (PTC) was undertaken to define an optimal management strategy for this rare condition. PTC is uncommon and its etiology of PTC is largely unknown although patients with familial hyperparathyroidism, multiple endocrine neoplasia type 1 and irradiation to the head and neck are at increased risk for developing the disease. PTC occurs with equal frequency in both sexes and is usually diagnosed in the fifth decade. En bloc resection of the carcinoma and the adjacent structures in the neck is the surgical treatment and is associated with an 8% local recurrence rate and a long term overall survival rate of 89% (mean follow up 69 months). In contrast simple parathyroidectomy results in a 51% local recurrence rate and 53% long-term survival rate (mean follow up 62 months). Adverse prognostic factors for survival were initial management with simple parathyroidectomy alone, the presence of nodal or distant metastatic disease at presentation and non-functioning PTC.

Parathyroid carcinoma

BACKGROUND

Parathyroid carcinoma is rare and represents 0.1% to 5% of the cases of hyperparathyroidism. New accounts are important to the understanding of these tumors. Experience in 9 cases is reported.

METHODS

From 1970 to 1995, 10 patients with parathyroid carcinoma demonstrated by clinical course or pathologic features of malignancy were treated. The patient's clinical data, laboratory and imaging examinations, surgical findings, pathology, recurrences, and survival were analyzed.

RESULTS

One male patient was excluded because of insufficient data. Average age was 51 years, with female:male ratio of 2:1. Average calcium level was 14,3 mg/dL. Palpable mass was found in 55%, bone disease in 89%, and renal disease in 78%. Four patients were reoperations. Five were operated on for hyperparathyroidism (1/tertiary). Capsular invasion was the most incident pathologic feature. Local recurrence occurred in 55%; neck node and bone metastasis in 11%, and lung in 33%. Two patients are alive and 5 died of disease.

CONCLUSIONS

Parathyroid carcinoma has clinical and laboratory features that can help diagnosis at the first surgery. It seems to have variable malignancy.