A case of primary hyperparathyroidism accompanying multiple myeloma

A Herald of Plasma Cell Myeloma: A Report of Malignant Plasma Cells Identified in Parathyroid Adenoma and a Review of Non-parathyroid Malignancies in Parathyroid Glands

Involvement of the parathyroid glands by non-parathyroid neoplasia is an infrequent event. Rare cases of metastases to the parathyroid gland have been reported in parathyroidectomies and autopsies of patients with known solid or hematopoietic malignancies. Here, we present a case of atypical clonal plasma cells incidentally identified within a parathyroid adenoma resected for hyperparathyroidism and hypercalcemia, which served as the sentinel event for a subsequent diagnosis of plasma cell myeloma. To our knowledge, this is the only reported case of a hematopoietic malignancy involving a parathyroid adenoma and the only reported case of malignant hematopoietic cells initially detected in parathyroidectomy.

A case of multiple myeloma coexisting with primary hyperparathyroidism and review of the literature

Hypercalcemia is a common medical problem with an estimated prevalence of 15% among hospitalized patients. Multiple myeloma (MM) and primary hyperparathyroidism (PHPT) are among the most common causes of hypercalcemia but coexistence of both pathologic processes in a patient is an extremely rare phenomenon. In this paper we have discussed a patient presenting with this rare phenomenon. We have also provided a comprehensive review of the scientific literature published on codiagnosis of MM and PHPT.

Contribution of multimodality imaging for positive and aetiological diagnosis of multiple brown tumours

This report concerns a rare case of multiple brown tumours discovered in a setting of primary hyperparathyroidism in a 64-year-old patient presenting with weight loss and leg pain. Biological, radiological and pathological findings led to the diagnosis of brown tumours. The contribution of anatomic and nuclear imaging techniques to the diagnosis of brown tumours and their aetiological assessment as well as pre-surgery localisation of parathyroid adenomas in the context of primary hyperparathyroidism is discussed.

Current management strategies for hypercalcemia

The two most common causes of hypercalcemia are primary hyperparathyroidism and neoplastic disease. Parathyroidectomy is the only curative intervention for the former condition. In the rare cases of patients with primary hyperparathyroidism who present with clinical symptoms due to their hypercalcemia, pharmacological treatment may be required. Fluid repletion and intravenous (IV) administration of bisphosphonates are recommended in the literature. Calcium receptor agonists (calcimimetic agents) are at the present time only available for use within clinical trials. Cancer patients usually present with symptoms of hypercalcemia. Rapid institution of antihypercalcemic treatment is essential in preventing life-threatening deterioration. Fluid repletion and administration of bisphosphonates are the treatment mainstays in hypercalcemia of malignancy. Five bisphosphonates are currently licensed in Europe for treatment of tumor-associated hypercalcemia: etidronate, clodronate, pamidronate, ibandronate, and zoledronate. In the US, pamidronate and zoledronate are licensed for use in this indication. Bisphosphonates containing nitrogen atoms (e.g. pamidronate, ibandronate, and zoledronate) are more potent than those without (e.g. etidronate, clodronate, and tiludronate). In patients with malignant hypercalcemia, the efficacy of the individual bisphosphonate depends on dose administered and initial serum calcium concentration. At present, pamidronate has been studied in the greatest number of investigations and in the largest number of patients. In the literature, the efficacy of pamidronate in restoring normocalcemia ranges between 40% and 100%, depending on the dose used and baseline serum calcium concentration. More recently, one study reported that pamidronate was inferior to zoledronate. In this study, the duration of response was also longer in the two zoledronate groups (30 and 40 days) than in the pamidronate group (17 days). The most serious adverse events of bisphosphonates concern renal function. Increases in serum creatinine levels have been more frequently reported following treatment of tumor-associated hypercalcemia with etidronate (8%) and clodronate (5%) than with the nitrogen-containing bisphosphonates pamidronate (2%) and ibandronate (1%). The frequency of increases in serum creatinine levels following treatment with zoledronate is difficult to estimate. Administration of the nitrogen-containing bisphosphonates has been associated with transient (usually mild) fever, lymphocytopenia, malaise, and myalgias. These events occur within 36 hours of the first dose and are self-limiting. Hypocalcemia occurs in up to 50% of patients treated with bisphosphonates for hypercalcemia of malignancy, although symptomatic hypocalcemia is rare. The toxicity and low efficacy of plicamycin (mithramycin) mean that use of this agent should be restricted to patients with hypercalcemia of malignancy who fail to respond to IV bisphosphonates. Calcitonin is characterized by good tolerability but poor efficacy in normalizing the serum calcium level. However, a major advantage of calcitonin is the acute onset of the hypocalcemic effect, which contrasts with the delayed but more pronounced effect of bisphosphonates. Combination calcitonin and bisphosphonate treatment may therefore be of value when rapid reduction of serum calcium is warranted. Gallium nitrate may be a valuable treatment for hypercalcemia of malignancy. It is characterized by high efficacy and few adverse events apart from renal toxicity (10% of cases). However, data are very limited and further trials are necessary.

Multiple Myeloma Presenting with Recurrent Hypercalcemia in a Patient aith a History of Primary Hyperparathyroidism: Report of Case and Review of Literature

OBJECTIVE

To report a case of primary hyperparathyroidism (PHPT) that presented with recurrent hypercalcemia due to multiple myeloma after successful parathyroidectomy.

METHODS

The initial manifestations, investigations, and postoperative follow-up of a case of hypercalcemia due to PHPT are described. The studies performed for evaluation for recurrent hypercalcemia and the subsequent diagnosis of multiple myeloma are discussed. The association between these disorders and reports of similar cases in the literature are reviewed.

RESULTS

A 72-year-old woman was referred for incidentally discovered hypercalcemia. She had no history of kidney stones or fractures. Further investigations revealed a high parathyroid hormone (PTH) level, hypercalciuria, and low bone mass, particularly at the cortical sites. Parathyroidectomy was performed, and a right inferior parathyroid adenoma was removed. Postoperatively, both the calcium and PTH levels normalized. She presented 9 months later with a 3-week history of pain in her left hip, polyuria, nausea, and vomiting. The patient had severe hypercalcemia and a suppressed PTH level. Further investigations revealed multiple bony lytic lesions, abnormalities on serum protein electrophoresis, and features consistent with multiple myeloma on a bone marrow biopsy specimen.

CONCLUSION

Hypercalcemia can occur in patients with PHPT and multiple myeloma; however, the occurrence of both disorders in the same patient is rare. Review of the literature revealed only a few cases similar to ours. Evidence in the literature suggests that monoclonal gammopathies occur more often in patients with PHPT than in the general population; therefore, screening for monoclonal gammopathy may be warranted in patients with PHPT.

Primary Hyperparathyroidism and Lymphoproliferative Diseases: Three Case Reports

Pathophysiologic mechanisms of malignancy-associated hypercalcemia are varied. The association of neoplasia and primary hyperparathyroidism (PHP) has been illustrated by clinical cases and by epidemiologic studies which have pointed to an increased risk of different malignancies during PHP. The authors report two cases of monoclonal gammapathy and one case of chronic lymphocytic leukemia (CLL) associated with PHP. A 58-year-old man presented with hypercalcemia due to PHP after remission for multiple plasmacytoma was obtained. A 70-year-old man was hospitalized for malaise, studies showed major hypercalcemia and benign monoclonal gammapathy. In the two cases, resolution of hypercalcemia was obtained by parathyroidectomy. The third patient was a 84-year-old woman with CLL who continued to deteriorate despite response to therapy, further studies confirmed hyperparathyroidism Physiopathogenic mechanisms of this association are discussed. The PHP-malignancy association should be considered ifthe symptoms or outcome of anyone of the two diseases are atypic.

Two cases of primary hyperparathyroidism associated with primary cutaneous lymphoma

Primary hyperparathyroidism has been described previously in association with malignancy, but to our knowledge has not been reported in association with primary cutaneous lymphoma. We report two cases of parathyroid adenoma with primary cutaneous lymphoma, the first in a 42-year-old woman with CD30-negative cutaneous large cell lymphoma, and the second in a 67-year-old man with mycosis fungoides and CD30-positive anaplastic large cell lymphoma.