Parathyroid carcinoma with metastatic calcification identified by technetium-99m methylene diphosphonate scintigraphy

Clinical characteristics and prognosis of dialysis patients with metastatic calcification diagnosed by 99mTc-MDP bone scintigraphy

To analyze the clinical characteristics of patients with metastatic calcification undergoing maintenance dialysis. Patients diagnosed with metastatic calcification via 99mTc-MDP bone scintigraphy between June 2019 and March 2023 at our hospital were included in this study. All patients were followed from the time of diagnosis until death, loss to follow-up, or the study endpoint (July 2023). The primary endpoint was all-cause mortality. The cohort comprised 7 males and 3 females, with a mean age of (48.7 ± 11.1) years. The most common sites of metastatic calcification included the lungs, joints, and skin, while rarer sites involved the stomach, myocardium, and mandibular angle. Nine patients received treatment with sodium thiosulfate, with a mean duration of STS administration of 23.5 days (range: 13.25 to 56.5 days). The mean follow-up duration was 14 months (range: 10 to 20 months). One patient died, one was lost to follow-up, while 8 out of 10 patients survived, and 6 out of 10 patients were followed for more than one year. 99mTc-MDP bone scintigraphy demonstrates high sensitivity and specificity for detecting metastatic calcification. The most frequently affected sites are the lungs, joints, and skin, with less common sites being the stomach, myocardium, and mandibular angle. Eight patients (8/10) survived, and 6 patients (6/10) remained alive with over one year of follow-up.

Fatal Generalized Metastatic Calcifications

Metastatic calcifications are a rare but potentially fatal complication of primary hyperparathyroidism (PHPT). In this case, a 76-year-old man with a previously asymptomatic PHPT developed a hypercalcemic crisis with severe pancreatitis following elective urologic surgery. Despite initial treatment focused on pancreatitis and subsequent organ failure, hypercalcemia persisted, leading to rapid progressive metastatic calcifications in multiple organs. Parathyroidectomy during ongoing pancreatitis successfully reduced calcium levels but not the calcifications. After 4 months of complications and persistent pain, the patient declined further treatment and ultimately succumbed to the disease. The current literature primarily reports single-organ metastatic calcifications due to PHPT. This case represents the only lethal case of systemic metastatic calcifications in the current century. Physicians should be aware of the potential deterioration of hypercalcemia following elective surgery, particularly in the context of renal impairment. Rapid correction of calcium levels may prevent severe complications such as fatal metastatic calcifications.

Metastatic pulmonary calcification: state-of-the-art review focused on imaging findings

Metastatic pulmonary calcification (MPC) is a subdiagnosed metabolic lung disease that is commonly associated with end-stage renal disease. This interstitial process is characterized by the deposition of calcium salts predominantly in the alveolar epithelial basement membranes. MPC is seen at autopsy in 60-75% of patients with renal failure. It is often asymptomatic, but can potentially progress to respiratory failure. Chest radiographs are frequently normal or demonstrate confluent or patchy airspace opacities. Three patterns visible on high-resolution computed tomography have been described: multiple diffuse calcified nodules, diffuse or patchy areas of ground-glass opacity or consolidation, and confluent high-attenuation parenchymal consolidation. The relative stability of these pulmonary infiltrates, in contrast to infectious processes, and their resistance to treatment, in the clinical context of hypercalcemia, are of diagnostic value. Scintigraphy with bone-seeking radionuclides may demonstrate increased radioactive isotope uptake. The resolution of pulmonary calcification in chronic renal failure may occur after parathyroidectomy, renal transplantation, or dialysis. Thus, the early diagnosis of MPC is beneficial. The aim of this review is to describe the main clinical, pathological, and imaging aspects of MPC.

Lymph node involvement and surgical approach in parathyroid cancer

BACKGROUND

The best surgical approach to parathyroid cancer is disputed. Recommendations vary and are built on incoherent evidence. High rates of recurrence and death require an in-depth review of underlying findings.

METHODS

This retrospective study includes 11 patients with parathyroid cancer who underwent surgery with central and/or lateral neck dissection by a single surgeon between 2005 and 2010. The diagnosis was based on histopathological criteria in all patients. Patterns of lymph node and soft tissue involvement of these and formerly reported patients were analysed based on full-text review of all published cases of parathyroid cancer.

RESULTS

In this series only 1 of 11 patients (9.1%) manifested lymph node metastasis. In the literature, lymph node metastases have been reported in only 6.5% of 972 published patients, or in 32.1% of the 196 in whom lymph node involvement was assessed by the authors. They were, with few exceptions, localised in the central compartment. Recurrence in soft tissue is more frequent than in locoregional lymph nodes.

CONCLUSION

Oncological en bloc clearance of the central compartment with meticulous removal of all possibly involved soft tissues, including a systematic central lymph node resection, may improve outcomes and should be included in the routine approach to the suspicious parathyroid lesion. There is no need for a prophylactic lateral neck dissection.

Vanishing polyuria and respiratory failure

A 44-year-old man with headache, sweating, subfebrile temperature and profound fatigue was found to have hypercalcaemic crisis with renal failure. Despite standard therapy, calcium levels remained high, he became anuric and developed multi-organ failure with acute respiratory distress syndrome requiring high ventilatory support, norepinephrine, dobutamine and continuous veno-venous haemodiafiltration. Ectopic calcification was found in the lungs, in the thyroid, kidneys, heart and stomach. A large parathyroid adenoma was then removed. When last seen, 11 months after surgery, the patient no longer required oxygen, and total lung capacity had returned to normal.

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.

[An historical case of malignant hyperparathyroidism with unusual metastatic sites]

We report a historical case of hyperparathyroidism in a young patient hospitalized for an array of osteolytic foci and incomplete fracture associated with a swollen neck, revealing a very special form of a metastatic parathyroid carcinoma with unusual multiple locations and exceptional medullary flooding. Carcinoma of the parathyroid gland produces a malignant hypersecreting tumor particularly difficult to diagnose. Treatment of this rare tumor is primarily surgical. The preoperative syndrome is unusually severe primary hyperparathyroidism. Intraoperatively, the size of the tumor and its local extension to surrounding tissue are highly suggestive. Confirmation requires pathological analysis of the operative specimens and can be further supported by the clinical course of local recurrence or metastasic spread. Specific immunohistochemical techniques have recently been shown to be contributive. The diagnosis is strengthened in the presence of associated Schantz and Castelman criteria. Foci of local extension can be identified preoperatively with ultrasound, (99m)Tc-sestamibi scintigraphy and MRI of the neck and mediastinum. The prognosis depends mainly on the possibility of achieving complete resection at the initial surgery. In some cases, very aggressive complementary postoperative radiotherapy is likely to improve locoregional control of the tumor. Chemotherapy alone or in combination with radiation has not demonstrated its effectiveness. The disease course and control can be monitored by regular assay of serum calcium and the parathormone.

Multiglandular parathyroid carcinoma: a case report and brief review

A 53-year-old man with no past medical history was admitted with complaints of hematuria, flank and abdominal pain of one week duration. He also complained of an enlarging new neck mass one month before presentation. The laboratory assessment showed a calcium level of 17.3 mg/dL (normal 8.5-10.5 mg/dL), serum albumin 2.9 g/dL (normal 3.0-5.0 g/dL), serum creatinine 3.4 mg/dL (normal 0.5-1.2 mg/dL). A neck ultrasound showed a complicated left neck mass. He was hydrated for one week with improvement in his labs, showing a decrease in serum calcium to 9.3 mg/dL and a serum creatinine of1.8 mg/dL. He underwent a total thyroidectomy and parathyroidectomy. The pathology showed multiglandular parathyroid carcinoma. It is important for the physician and surgeon dealing with primary hyperparathyroidism to look for parathyroid carcinoma. A better knowledge and understanding of this condition would aid in early diagnosis and possibly increase the survival rate.

Parathyroid Cancer

Parathyroid cancer is a rare endocrine tumor and an uncommon cause of HPT. Advances have been made to identify a promising molecular diagnostic marker for the disease. The use of accurate preoperative imaging modalities would undoubtedly facilitate its management by making an accurate preoperative diagnosis by assessing its invasiveness, and by searching for nodal or distant metastases. The effectiveness of the application of intraoperative PTH assay in the management of this rare condition remains to be seen. Radical surgical treatment offers the best chance of cure, but for patients who have refractory unresectable disease or metastases, the availability of more effective targeted medical therapy may palliate the debilitating symptoms of hypercalcemia, reduce its metabolic complications, and potentially improve survival.

Metastatic calcifications and severe hypercalcemia in a patient with parathyroid carcinoma

Primary hyperparathyroidism is rarely produced by parathyroid carcinoma. We present the case of a 63-yr-old man who was admitted due to recent onset of constipation, weakness and progressive lethargy. At physical examination, a left cervical mass was palpated. Marked hypercalcemia (serum calcium 25 mg/dl) (6.22 mmol/l) complicated by renal insuficiency (serum creatinine 4.4 mg/dl) (388 micromol/l) was found, but both were unresponsive to conventional therapy and hemofiltration. Autopsy examination showed a carcinoma of the upper left parathyroid gland, multiple foci of metastatic calficications in the vessel walls and parenchyma of both lungs and kidneys, and the myocardium, which contributed to multi-organ failure and death. In addition to describing the clinical presentation, we review the mechanism of metastatic calcifications as well as the role of renal function and hyperphosphatemia, and the basis for therapy of hypercalcemic crisis.

The management of parathyroid carcinoma

PURPOSE OF REVIEW

To summarize the current treatment approaches to parathyroid malignancy.

RECENT FINDINGS

Recent advances in molecular biology are aiding the understanding of the pathogenesis of this condition, and imaging modalities are contributing to localization of the abnormal parathyroid tissue.

SUMMARY

The treatment of parathyroid malignancy is overwhelmingly surgical, comprising an initial en bloc resection of the tumor and adjacent structures. The risk of tumor recurrence is high and may require several metastasis resections in order to control symptoms of hypercalcemia.

Calcium deposition with or without bone formation in the lung

Pulmonary calcification and ossification occurs with a number of systemic and pulmonary conditions. Specific symptoms are often lacking, but calcification may be a marker of disease severity and its chronicity. Pathophysiologic states predisposing to pulmonary calcification and ossification include hypercalcemia, a local alkaline environment, and previous lung injury. Factors such as enhanced alkaline phosphatase activity, active angiogenesis, and mitogenic effects of growth factors may also contribute. The clinical classification of pulmonary calcification includes both metastatic calcification, in which calcium deposits in previously normal lung or dystrophic calcification, which occurs in previously injured lung. Pulmonary ossification can be idiopathic or can result from a variety of underlying pulmonary, cardiac, or extracardiopulmonary disorders. The diagnosis of pulmonary calcification and ossification requires various imaging techniques, including chest radiography, computed tomographic scanning, and bone scintigraphy. Interpretation of the presence of and the specific pattern of calcification or ossification may obviate the need for invasive biopsy. In this review, specific conditions causing pulmonary calcification or ossification that may impact diagnostic and treatment decisions are highlighted. These include metastatic calcification caused by chronic renal failure and orthotopic liver transplantation, dystrophic calcification caused by granulomatous disorders, DNA viruses, parasitic infections, pulmonary amyloidosis, vascular calcification, the idiopathic disorder pulmonary alveolar microlithiasis, and various forms of pulmonary ossification.

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.