Kosin Med J.  2022 Sep;37(3):255-259. 10.7180/kmj.22.103.

Secondary hyperparathyroidism due to multiple parathyroid carcinomas in a patient with chronic hemodialysis: a case report

• Ryang S
• Yi W
• Kim M
• Song SH
• Lee BJ
• Kim BH

• KMID: 2538806
• DOI: http://doi.org/10.7180/kmj.22.103

Abstract

Parathyroid carcinoma (PC) in cases of secondary or tertiary hyperparathyroidism is relatively uncommon, and only a few case reports have described this entity. Although some papers have reported patients with one or two parathyroid malignancies, multiple PC–especially three or more–have been even more rarely reported. Herein, we report a case of secondary hyperparathyroidism due to multiple PCs in a chronic hemodialysis patient. A 54-year-old man with end-stage kidney disease was referred for hyperparathyroidism. He had been diagnosed with chronic kidney disease in 2001 and had begun hemodialysis in 2009. In laboratory tests, intact parathyroid hormone (iPTH) was markedly elevated to 1,144.1 pg/mL (normal range: 15.0–68.3 pg/mL) and serum calcium was mildly elevated to 10.56 mg/dL (normal range: 8.5–10.3 mg/dL). Ultrasonography showed hypoechoic nodules in the posterior part of both thyroid glands. All three nodules showed increased uptake on a 99mTc sestamibi scan. The patient underwent total parathyroidectomy with autotransplantation to the right forearm. Histopathology findings showed three PCs with capsular invasion and one parathyroid hyperplasia. In the immediate postoperative period, the iPTH level dropped from 1,446.8 to 82.4 pg/dL and, after 1 month, to 4.0 pg/dL. This patient needed oral calcium carbonate and active vitamin D to maintain appropriate serum calcium levels. Although multiple PCs are rare, they can cause secondary hyperparathyroidism. Therefore, clinicians should suspect multiple PCs when patients’ serum iPTH levels are exceptionally high. Additionally, since PCs could occur in multiple glands, autotransplantation of the parathyroid gland after parathyroidectomy should be done carefully.

Keyword

Case reports; Chronic kidney disease; Multiple parathyroid neoplasm; Secondary hyperparathyroidism

Figure

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  Fig. 1. Ultrasonography and 99mTc sestamibi single photon emission computed tomography (SPECT) of parathyroid glands (arrow). (A) Right superior parathyroid gland. (B) Left superior parathyroid gland. (C) Left inferior parathyroid gland. (D) Parathyroid SPECT images acquired 20 minutes and 2 hours after the intravenous 99mTc sestamibi injection. CA, carotid artery; TR, trachea, ANT, anterior; LAO, left anterior oblique; RAO, right anterior oblique.

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  Fig. 2. Postoperative gross and microscopic histology of each parathyroid gland. Gross pathology images of (A) the right superior parathyroid gland, (B) the left superior parathyroid gland, (C) the right inferior parathyroid gland, and (D) the left inferior parathyroid gland. Microscopic examinations of three parathyroid carcinomas: (E) right superior parathyroid gland (H&E, ×40), (F) left superior parathyroid gland (H&E, ×40), (G) left inferior parathyroid gland (H&E, ×40). Capsular invasion is indicated by an arrow.

Reference

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