Endocrine Abstracts

Parathyroid carcinoma accounts for 0.5–5% of primary hyperparathyroidism. Preoperative diagnosis is difficult.

A 33-year-old butcher presented in July 2007 with a 3 month history of nausea, abdominal pain, loss of appetite, general weakness and 1 stone weight loss. He denied polyuria, polydipsia or bone pain.

Past history included Raynaud’s disease, depression and panic attacks. His regular medications were omeprazole and proranolol.

His father had anaplastic thyroid cancer.

General and systemic examinations were normal including neck examination.

On admission, his calcium level was 3.69 mmol/l, PTH 60.7 pmol/l and ALP 299 IU/l. Renal function, thyroid function and CXR were normal. There was no evidence of parathyroid adenoma on USS neck. Sestamibi scan showed suprasternal parathyroid adenoma which was confirmed on MRI. Serum calcium fell to 2.49 with IV hydration and Pamidronate.

The patient underwent targeted parathyroidectomy for presumed adenoma. At operation, the lesion was discrete and mobile and intraoperative frozen section showed parathyroid adenoma. However, histology was consistent with parathyroid carcinoma (capsular invasion, broad fibrous bands and extension into the surrounding tissue, but no vascular invasion).

This case pointed out the importance of clinical suspicion of parathyroid carcioma in primary hyperparathyroidism. Severe hypercalcaemia, very high PTH level, palpable neck mass, evidence of bone and renal complications should alert clinicians and surgeons to consider the possibility of parathyroid carcinoma. Treatment includes surgery, adjuvant radiation and treatment of hypercalcaemia. Hypercalcaemia is the main cause of morbidity and mortality.

Literature analysis shows that the use of parafibromin immunobiochemistry on intraoperative frozen section may resolve diagnostic problem and complete resection of tumour at initial operation provides the best chance of cure.