Endocrine Abstracts

A 69-year-old man with longstanding ulcerative colitis presented for annual review by the gastroenterologists. He complained of lower back pain for six months and a recent history of anorexia, constipation, thirst and urinary frequency.

His serum calcium was 5.12 mmol/l, phosphate 1.77 mmol/l, urea 19.1 mmol/l and creatinine 252 μmol/l.

He was admitted, rehydrated with 5 l of intravenous normal saline over 24 h and given pamidronate 90 mg, but remained unwell and hypercalcaemic.

The endocrinologists were informed of his admission. On examination, a mass was palpable in the right anterior cervical triangle and an urgent parathyroid hormone (PTH) level requested. His PTH was 192.9 pmol/l and a neck ultrasound was performed that morning; this identified a heterogeneous nodule (4.1×3.8×2.3 cm), separate to the thyroid, thought to represent a right superior parathyroid adenoma. The size of the nodule and the PTH level raised concerns of a parathyroid carcinoma. After liaising with the surgeons, he had a parathyroidectomy that afternoon and required intensive care post-operatively for renal support.

His recovery was uneventful with no significant hypocalcaemia. The pathologists reported a parathyroid neoplasm of uncertain malignant potential.

Following the diagnosis of parathyroid carcinoma, he is seen regularly. His calcium levels are within normal limits, but his PTH remains elevated (29.8 pmol/l at his last visit) and he is vitamin D deficient.

Parathyroid carcinoma is a rare cause of PTH-related hypercalcaemia. Histopathological distinction between benign and malignant parathyroid tumours is difficult.

Surgery is the most effective treatment in cases of severe hypercalcaemia and the timely collaboration between the different specialties in this case was essential to this man receiving prompt and appropriate treatment.