History

Fact Explanation
Introduction Parathyroid carcinoma is a rare entity of endocrine malignancies thatcan cause heperparathyroidism.[1,2] Its course is typically indolent but progressive.[1] It may be locally invasive or metastatic. [5] This has a high mortality due to intractable hypercalcaemia. [2]
Asymptomatic Majority of neoplasms are secreting parathyroid hormone and appears as hyperparathyroidism. Only a small fraction is non-functional tumours. [2]
Hoarseness of voice [1,4] Locally advanced disease causes infiltration of recurrent laryngeal nerve.[1]
Dysphagia [1,4] Locally advanced disease causes compressive symptoms. [1]
History of neck irradiation or exposure to radiation Exposure to radiation increases the risk of benign parathyroid diseases. Also it increases the risk of thyroid and parathyroid cancers. But evidences suggesting it as an etiologic factor in parathyroid carcinoma remains unclear.[2]
Family history of parathyroid carcinoma or hypeparathyroidism Parathyroid malignancies sometimes associated with hereditary syndromes of hyperparathyroidism, particularly in hyperparathyroidism-jaw tumor syndrome[1] It is also associated with MEN-1 syndrome. [1]
Recuurent epigastric pain radiating to back Associated with recurrent pancreatitis due to hypercalcaemia. [2]
Symptoms of hypercalcaemia:[1,2,3] :Fatigue, weakness, confusion, depression, constipation, polyuria, polydypsia The typical clinical picture is characterized by signs and symptoms of severe hypercalcemia. [1,2,3,4]
Bone pain and pathologic fractures [1] Bones are frequently affected as parathyroid hormone causes bone resorption, leading to bone pain and pathological fractures and osteoporosis. [6] Bone involvement due to hyperparathyroidism causes bone pain ,pathological fractures and other bone diseases.[1,2,4]
Renal colics [1] Hypersecreted parathyroid hormone acts on kidney, and reduce the excretion of calcium via urine. Increased calcium can precipitate as stones[2,3] This nephrocalcinosis causing loin to groin pain. Most of them are calcium oxalate and occasionally calcium phosphate.
Neurological problems Neurological problems are a well defined manifestation of hyperparathyroidism. [7] There can be abnormalities in calcium transport across the cell membrane due to hypercalcaemia. [8]. Manifestations will be proximal muscle weakness, easy fatigubility, ansomnia, depression and poor memory.
References
  1. MARCOCCI C, CETANI F, RUBIN MR, SILVERBERG SJ, PINCHERA A, BILEZIKIAN JP. Parathyroid Carcinoma J Bone Miner Res [online] 2008 Dec, 23(12):1869-1880 [viewed 30 September 2014] Available from: doi:10.1359/jbmr.081018
  2. SHARRETTS JM, KEBEBEW E, SIMONDS WF. Parathyroid Cancer Semin Oncol [online] 2010 Dec, 37(6):580-590 [viewed 30 September 2014] Available from: doi:10.1053/j.seminoncol.2010.10.013
  3. MCCANCE DR, KENNY BD, SLOAN JM, RUSSELL CF, HADDEN DR. Parathyroid carcinoma: a review. J R Soc Med [online] 1987 Aug, 80(8):505-509 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1290959
  4. WILKINS BJ, LEWIS JS JR. Non-Functional Parathyroid Carcinoma: A Review of the Literature and Report of a Case Requiring Extensive Surgery Head Neck Pathol [online] , 3(2):140-149 [viewed 30 September 2014] Available from: doi:10.1007/s12105-009-0115-4
  5. GOEPFERT H, SMART CR, ROCHLIN DB. Metastatic parathyroid carcinoma and hormonal chemotherapy. Case report and response to hexestrol. Ann Surg [online] 1966 Nov, 164(5):917-920 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477091
  6. CARNEVALE V, ROMAGNOLI E, PIPINO M, SCILLITANI A, D'ERASMO E, MINISOLA S, MAZZUOLI G. [Primary hyperparathyroidism]. Clin Ter [online] 2005 Sep-Oct, 156(5):211-26 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16382970
  7. PYRAM R, MAHAJAN G, GLIWA A. Primary hyperparathyroidism: Skeletal and non-skeletal effects, diagnosis and management. Maturitas [online] 2011 Nov, 70(3):246-55 [viewed 24 June 2014] Available from: doi:10.1016/j.maturitas.2011.07.021
  8. ZHU X, ZHAI H, TANG SF, CHENG Y. Intrathyroidal parathyroid adenoma presenting with neuromuscular manifestation. Neurol India [online] 2009 May-Jun, 57(3):340-3 [viewed 25 June 2014] Available from: doi:10.4103/0028-3886.53280

Examination

Fact Explanation
Palpable neck mass Most non-functional parathyroid carcinoma present as locally advanced disease.[1]
Hoarseness of voice Locally advanced disease causes infiltration of recurrent laryngeal nerve.[1]
Keratopathy Calcium precipitation across the cornea in the palpebral aperture due to hypercalcaemia may cause keratopathy. [5]
Pallor Aneamia may be due to several causes such as peptic ulcer disease due to hypercalcaemia, [1] and hypercalcaemic nephropathy. [1]
Dehydration Due to hypercalcaemia they can have polyuria, polydypsia. [6]
Depressed mood One of the major manifestation of hypercalcaemia. [7]
Nervous system examination: confusion, hypotonia,hyporeflexia, paresis, coma Due to the neurological manifestations in hypercalcaemia. [4]
CVS Examination: low blood pressure and increase pulse rate/ irregular pulse Due to volume depletion and renal failure. [3]
Abdominal examination: Fecal impaction , enlarged liver, epigastric tenderness Hypercalcaemia causes constipation, [2] pancreatitis.This may also be due to due to metastasis there may be hepatic involvement.
References
  1. MARCOCCI C, CETANI F, RUBIN MR, SILVERBERG SJ, PINCHERA A, BILEZIKIAN JP. Parathyroid Carcinoma J Bone Miner Res [online] 2008 Dec, 23(12):1869-1880 [viewed 30 September 2014] Available from: doi:10.1359/jbmr.081018
  2. RAGNO A, PEPE J, BADIALI D, MINISOLA S, ROMAGNOLI E, SEVERI C, D'ERASMO E. Chronic constipation in hypercalcemic patients with primary hyperparathyroidism. Eur Rev Med Pharmacol Sci [online] 2012 Jul, 16(7):884-9 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22953636
  3. KHAN AA. Medical management of primary hyperparathyroidism. J Clin Densitom [online] 2013 Jan-Mar, 16(1):60-3 [viewed 24 June 2014] Available from: doi:10.1016/j.jocd.2012.11.010
  4. PYRAM R, MAHAJAN G, GLIWA A. Primary hyperparathyroidism: Skeletal and non-skeletal effects, diagnosis and management. Maturitas [online] 2011 Nov, 70(3):246-55 [viewed 24 June 2014] Available from: doi:10.1016/j.maturitas.2011.07.021
  5. JAVADI MA, REZAEI KANAVI M, FARAMARZI A, FEIZI S, AZIZI F, JAVADI F. Confocal Scan Imaging and Impression Cytology of the Cornea in a Case of Multiple Endocrine Neoplasia Type-2b J Ophthalmic Vis Res [online] 2012 Apr, 7(2):176-179 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520471
  6. MISCHIS-TROUSSARD C, GOUDET P, VERGES B, COUGARD P, TAVERNIER C, MAILLEFERT JF. Primary hyperparathyroidism with normal serum intact parathyroid hormone levels. QJM [online] 2000 Jun, 93(6):365-7 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10873186
  7. ZHU X, ZHAI H, TANG SF, CHENG Y. Intrathyroidal parathyroid adenoma presenting with neuromuscular manifestation. Neurol India [online] 2009 May-Jun, 57(3):340-3 [viewed 25 June 2014] Available from: doi:10.4103/0028-3886.53280

Differential Diagnoses

Fact Explanation
Primary hyperparathyroidism There is an autonomous production of parathyroid hormone by the parathyroid glands which leads to elevated serum parathyroid hormone and hypercalcemia/normocalcemia. [2] Normocalcemic primary hyperparathyroidism is a variety that incidentally diagnosed with reduced bone mineral density. [3] They can also present with hypercalcaemic emergencies.Features that are favour of parathyroid carcinoma rather than benign primary hyperparathyroidism are male gender, younger age, serum calcium > 14 mg/dL, serum PTH 3-10 times the upper limit of normal, palpable neck mass, recurrent laryngeal nerve palsy, renal involvement, skeletal involvement, concomitant renal and skeletal disease, recurrent severe pancreatitis, peptic ulcer disease, anemia, and personal or family history of hereditary hyperparathyroidism-jaw tumor syndrome. [1]
Secondary hyperparathyroidism This usually occurs in disease conditions such as chronic kidney disease and malabsorption. This usually develops in response to hypocalcaemia, Calcium will be low or normal and parathyroid hormone level will be high. [3]
Tertiary hyperparathyroidism This usually occurs after long-term history of secondary hyperparathyroidism as in the case of, chronic kidney disease, due to the hyperplasia of glands. [4] Gland will autonomously secrete parathyroid hormone after continuous stimulation. Calcium and parathyroid hormone level, both will be high as in primary hyperparathyroidism. Clinical features may be same as in the other types of hyperparathyroidism.
Parathyroid adenoma This is atype of primary hyperparathyroidism leading to excess secretion of parathyroid hormone by the parathyroid galmnd. Fatigue, muscle weakness, and bone pain are common in patients with adenomas, and also have other features of hyperparathyroidism. [5] Investigations will show elevated parathyroid hormone with hypercalcemia/normocalcemia. [2]
Paraneoplastic syndrome Paraneoplastic syndromes occur involving different tissues, like example dermatological, neuronal or endocrinological paraneoplastic syndromes. Paraneoplastic hypercalcemia may occur without the bone metastases. It is reported in patients with lung cancer, breast cancer or multiple myeloma. [7] This is induced by a tumor-associated peptide-releasing hormone and may show similar features of hypercalcemia.
Hypercalcaemia Hypercalcaemia is defined as serum calcium >2.6mmol/l. [6] Hypercalcaemia may be associated either with an elevated or inappropriately normal PTH level,or reuced PTH level depending on the aetiology. Conditions leading to primary, secondary and tertiary hyperparathyroidism, drugs such as calcium, thiazide, lithium and malignancies such as bone metastases, multiple myeloma are the causative factors for the hypercalcaemia. [6] Symptoms may be polyuria, poltdypsia, constipation, thirst and neurological manifestations. Volume contraction secondary to diarrhoea, vomiting, may aggravate the symptoms hypercalcaemia.[6]
Familial hypocalciuric hypercalciuria The problem is in the calcium sensing receptor of the parathyroid glands. There will be low urinary calcium in 24h urine, and calcium/creatinine clearance ratio is decreased. [3]
References
  1. TAN AH, KIM HK, KIM MY, OH YL, KIM JS, CHUNG JH, KIM SW. Parathyroid Carcinoma Presenting as a Hyperparathyroid Crisis Korean J Intern Med [online] 2012 Jun, 27(2):229-231 [viewed 30 September 2014] Available from: doi:10.3904/kjim.2012.27.2.229
  2. CARNEVALE V, ROMAGNOLI E, PIPINO M, SCILLITANI A, D'ERASMO E, MINISOLA S, MAZZUOLI G. [Primary hyperparathyroidism]. Clin Ter [online] 2005 Sep-Oct, 156(5):211-26 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16382970
  3. MARTíNEZ CORDELLAT ISABEL. Hyperparathiroidism: Primary or Secondary Disease?. Reumatología Clínica (English Edition) [online] 2012 September, 8(5):287-291 [viewed 25 June 2014] Available from: doi:10.1016/j.reumae.2011.06.002
  4. PITT SUSAN C., PANNEERSELVAN RAJARAJAN, CHEN HERBERT, SIPPEL REBECCA S.. Secondary and Tertiary Hyperparathyroidism: The Utility of ioPTH Monitoring. World J Surg [online] December, 34(6):1343-1349 [viewed 25 June 2014] Available from: doi:10.1007/s00268-010-0575-4
  5. TEZELMAN S, SHEN W, SHAVER JK, SIPERSTEIN AE, DUH QY, KLEIN H, CLARK OH. Double parathyroid adenomas. Clinical and biochemical characteristics before and after parathyroidectomy. Ann Surg [online] 1993 Sep, 218(3):300-309 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1242968
  6. CARROLL R, MATFIN G. Endocrine and metabolic emergencies: hypercalcaemia Ther Adv Endocrinol Metab [online] 2010 Oct, 1(5):225-234 [viewed 30 September 2014] Available from: doi:10.1177/2042018810390260
  7. LINNEMANN THOMAS, MüLLER FRAUKE, LöHNERT MATHIAS, HIRNLE PETER, GöRNER MARTIN. Successful treatment of paraneoplastic hypercalcemia in a patient with giant condyloma acuminatum: a case report. Array [online] 2013 December [viewed 30 September 2014] Available from: doi:10.1186/1752-1947-7-251

Investigations - for Diagnosis

Fact Explanation
Serum Calcium Levels are usually elevated more markedly than seen with benign primary hyperparathyroidism. [7] Parathyroid hormone assay is the most useful test for differentiating hyperparathyroidism from malignancy and other causes of hypercalcemia. [1]
Serum calcium and phosphate level Calcium is almost always high. [3,7] Serum phosphate may be low. [3]
Alkaline phosphate level May be high [3] due to bone resorption.
24 hour urinary calcium Increased due to hypercalcaemia. [3]
X-ray -Hand -Skull Hand x-ray will show subperiosteal bone resorption of the distal phalanges. On X-ray imaging, brown tumors will be appearing as lytic lesions. [2] Other changes would be osteopenia, 'salt-and-pepper' appearance on skull x-ray, subperiostal bone resorption and patchy diffuse areas of osteoclerosis.
Cervical ultrasound, computer tomography , CT scan and magnetic resonance imaging of the neck This will demonstrate the parathyroid adenoma, carcinoma and lymph node enlargement. [4] Extent of the lesion, echogenic structure, solid areas may be seen. A CT scan of the neck and upper mediastinum may reveal a cystic tumor in the region. [5] Advantages of USS are low costs, repeatability and no radiation load. [5]
Technetium-99m sestamibi (99mTc-MIBI) scintigraphy Technetium-99m sestamibi (99mTc-MIBI) scintigraphyis a basic important for the to the preoperative diagnosis. [5]
FNAC and biopsy This may be harmful and care should be taken not tu rupture the capsule preoperetively. [6]
References
  1. ASSADI F. Hypercalcemia: an evidence-based approach to clinical cases. Iran J Kidney Dis [online] 2009 Apr, 3(2):71-9 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19395781
  2. VERA LARA, DOLCINO MARA, MORA MARCO, ODDO SILVIA, GUALCO MARINA, MINUTO FRANCESCO, GIUSTI MASSIMO. Primary hyperparathyroidism diagnosed after surgical ablation of a costal mass mistaken for giant-cell bone tumor: a case report. Array [online] 2011 December [viewed 25 June 2014] Available from: doi:10.1186/1752-1947-5-596
  3. ZHU X, ZHAI H, TANG SF, CHENG Y. Intrathyroidal parathyroid adenoma presenting with neuromuscular manifestation. Neurol India [online] 2009 May-Jun, 57(3):340-3 [viewed 25 June 2014] Available from: doi:10.4103/0028-3886.53280
  4. TOMASELLA G. [Diagnostic imaging in primary hyperparathyroidism. Radiological techniques: US--CAT--MR]. Minerva Endocrinol [online] 2001 Mar, 26(1):3-12 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11323562
  5. HALENKA M, KARASEK D, FRYSAK Z. Four Ultrasound and Clinical Pictures of Parathyroid Carcinoma Case Rep Endocrinol [online] 2012:363690 [viewed 30 September 2014] Available from: doi:10.1155/2012/363690
  6. TAN AH, KIM HK, KIM MY, OH YL, KIM JS, CHUNG JH, KIM SW. Parathyroid Carcinoma Presenting as a Hyperparathyroid Crisis Korean J Intern Med [online] 2012 Jun, 27(2):229-231 [viewed 30 September 2014] Available from: doi:10.3904/kjim.2012.27.2.229
  7. GOEPFERT H, SMART CR, ROCHLIN DB. Metastatic parathyroid carcinoma and hormonal chemotherapy. Case report and response to hexestrol. Ann Surg [online] 1966 Nov, 164(5):917-920 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC147709

Investigations - Fitness for Management

Fact Explanation
Arterial blood gas Hyperchloremic metabolic acidosis occur in hyperparathyroidism. [1]
References
  1. ASSADI F. Hypercalcemia: an evidence-based approach to clinical cases. Iran J Kidney Dis [online] 2009 Apr, 3(2):71-9 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19395781

Investigations - Followup

Fact Explanation
Serum calcium levels Serum calcium levels needs to be monitored after surgery as there can be complications like hungry bone syndrome following parathyroidectomy. Calcium level returns to normal within 24 to 48 hours of surgery. [1]
Disease activity Serum calcium, phosphate and parathyroid hormone levels are important to assess disease activity. [2]
DEXA scan Useful in patients who are known to have osteoporosis as a complication. [2]
References
  1. KIM KM, PARK JB, BAE KS, KANG SJ. Hungry bone syndrome after parathyroidectomy of a minimally invasive parathyroid carcinoma J Korean Surg Soc [online] 2011 Nov, 81(5):344-349 [viewed 30 September 2014] Available from: doi:10.4174/jkss.2011.81.5.344
  2. HEDBäCK G, ODéN A. Recurrence of hyperparathyroidism; a long-term follow-up after surgery for primary hyperparathyroidism. Eur J Endocrinol [online] 2003 Apr, 148(4):413-21 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12656661 doi:10.1016/j.maturitas.2011.07.021
  3. PYRAM R, MAHAJAN G, GLIWA A. Primary hyperparathyroidism: Skeletal and non-skeletal effects, diagnosis and management. Maturitas [online] 2011 Nov, 70(3):246-55 [viewed 24 June 2014] Available from: doi:10.1016/j.maturitas.2011.07.021

Investigations - Screening/Staging

Fact Explanation
Renal function tests(blood urea, serum creatinine[1], serum electrolytes) Loss of renal function [3] is a can be a complication of hypercalcaemia, and phosphate retention.
Electrocardiogram Hypercalcaemia can cause shortening of QT interval [4] and elevation of ST segment [5] which can mimics acute myocardial infarction.
Echocardiogram There can be left ventricular hypertrophy and myocardial calcific deposits. [2]
DEXA scan (Dual-emission X-ray absorptiometry) This is to detect osteoporosis and Z -score <-2.0 forearm is suggestive of osteoporosis. [3]
References
  1. WALSER M. Assessing renal function from creatinine measurements in adults with chronic renal failure. Am J Kidney Dis [online] 1998 Jul, 32(1):23-31 [viewed 24 June 2014] Available from: doi:10.1053/ajkd.1998.v32.pm9669420
  2. STEFENELLI T, GLOBITS S, BERGLER-KLEIN J, WOLOSZCZUK W, LäNGLE F, NIEDERLE B. [Cardiac changes in patients with hypercalcemia]. Wien Klin Wochenschr [online] 1993, 105(12):339-41 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8333202
  3. PYRAM R, MAHAJAN G, GLIWA A. Primary hyperparathyroidism: Skeletal and non-skeletal effects, diagnosis and management. Maturitas [online] 2011 Nov, 70(3):246-55 [viewed 24 June 2014] Available from: doi:10.1016/j.maturitas.2011.07.021
  4. AHMED R, HASHIBA K. Reliability of QT intervals as indicators of clinical hypercalcemia. Clin Cardiol [online] 1988 Jun, 11(6):395-400 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2899466
  5. NISHI SP, BARBAGELATA NA, ATAR S, BIRNBAUM Y, TUERO E. Hypercalcemia-induced ST-segment elevation mimicking acute myocardial infarction. J Electrocardiol [online] 2006 Jul, 39(3):298-300 [viewed 24 June 2014] Available from: doi:10.1016/j.jelectrocard.2005.10.015

Management - General Measures

Fact Explanation
Patient education Patient should be educated on the nature of the disease, complication, treatment options and side effects of the treatments. Its course is typically indolent but may be progressive. [7] Proper counselling about the complications of the surgery is required.
Resuscitaion ABCDE checcck up to assess the airway, breathing, circulation, disability, and examination and evaluation is nesessary in emergency situations as acute management of hypercalcaemia. [6]
Rehydration Hypercalcemia caused by parathyroid cancer is often severe. Rehydration would be one of the earliest step in managing hypercalcaemia. [1] Aggressive rehydration with intravenous (IV) normal saline is required. [5]
Management of hypercalcaemia Phosphate therapy can be used to correct hypercalcaemia as an oral or parentaral therapy. This would be the choice in managing patients with hypercalcaemia after failed parathyroidectomy. [2] 1-3g of phosphorous per day is given with checking Ca daily in the initial period. Acute hypercalcaemia can be managed with intravenous phosphate therapy [4] specially if the patient is in coma situation. This improves the calcium soon, but patient should be started on oral phosphate as soon as possible. Sodium ethylene diamine tetraacetate is a calcium chelating agent. [2] Given as an intravenous infusion. Furosemide Helps in excretion of calcium. [2] It is contraindicated in kidney failure. Calcitonin is important in managing severe hypercalcaemia by inhibiting the bone turn over. [3]
References
  1. LYELL VERONICA, KHATAMZAS ELHAM, ALLAIN THERESA. Severe hypercalcaemia and lymphoma in an HTLV-1 positive Jamaican woman: a case report. J Med Case Rep [online] 2007 December [viewed 14 September 2014] Available from: doi:10.1186/1752-1947-1-56
  2. PATERSON CR. Drugs for the treatment of hypercalcaemia Postgrad Med J [online] 1974 Mar, 50(581):158-162 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495534
  3. RALSTON SH. Medical management of hypercalcaemia. Br J Clin Pharmacol [online] 1992 Jul, 34(1):11-20 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1381369
  4. LYELL VERONICA, KHATAMZAS ELHAM, ALLAIN THERESA. Severe hypercalcaemia and lymphoma in an HTLV-1 positive Jamaican woman: a case report. J Med Case Rep [online] 2007 December [viewed 14 September 2014] Available from: doi:10.1186/1752-1947-1-56
  5. TAN AH, KIM HK, KIM MY, OH YL, KIM JS, CHUNG JH, KIM SW. Parathyroid Carcinoma Presenting as a Hyperparathyroid Crisis Korean J Intern Med [online] 2012 Jun, 27(2):229-231 [viewed 30 September 2014] Available from: doi:10.3904/kjim.2012.27.2.229
  6. CARROLL R, MATFIN G. Endocrine and metabolic emergencies: hypercalcaemia Ther Adv Endocrinol Metab [online] 2010 Oct, 1(5):225-234 [viewed 30 September 2014] Available from: doi:10.1177/2042018810390260
  7. MARCOCCI C, CETANI F, RUBIN MR, SILVERBERG SJ, PINCHERA A, BILEZIKIAN JP. Parathyroid Carcinoma J Bone Miner Res [online] 2008 Dec, 23(12):1869-1880 [viewed 30 September 2014] Available from: doi:10.1359/jbmr.081018

Management - Specific Treatments

Fact Explanation
Surgery Parathyroid carcinoma can often be cured by adequate surgical excision at an early stage. [1] Meticulous en bloc resection is the onlyoption available for the cure of parathyroid cancer. [2] Rupture of the tumor capsule either preoperatively during needle aspiration or intraoperatively should be happened. [2] Aggressive en bloc removal of the affected parathyroid gland with ipsilateral thyroidectomy and isthmusectomy should bedone and the sample is sent for histopathological analysisto see the local vascular, capsular, and soft tissue invasion of the tumour. [2]
Post op care Hungry bone syndrome is a significant complication occurring after surgical removal of parathyroids and may require postoperative calcium. [3] It is a postoperative hypocalcemic state as a result of remineralization of various minerals, including calcium, of the bone. It needs long-term supplementation of calcium. [3]
Management of metastases Distant metastases are less frequent in parathyroid carcinoma and is causing , hypercalcemia that is poorly controlled by hormonal, chemotherapy, or radiation therapy. [1]
Management of recurrances Carcinoma already spread outside the capsule or implanted at surgery, increases the chance of local recurrence. Reoperation for local and regional recurrence is the option for management. [1]
External beam radiation therapy External beam radiation therapy (EBRT) is controversial, but may be given to the carcinoma with capsular invasion on histopathology as an adjuvant therapy. It is administered to the tumor bed and regional lymphatics. [2]
Chemotherapy Synthetic oestrogen compounds are useful in treatin g the metastatic carcinoma. [4]
References
  1. FLYE MW, BRENNAN MF. Surgical resection of metastatic parathyroid carcinoma. Ann Surg [online] 1981 Apr, 193(4):425-435 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1345095
  2. TAN AH, KIM HK, KIM MY, OH YL, KIM JS, CHUNG JH, KIM SW. Parathyroid Carcinoma Presenting as a Hyperparathyroid Crisis Korean J Intern Med [online] 2012 Jun, 27(2):229-231 [viewed 30 September 2014] Available from: doi:10.3904/kjim.2012.27.2.229
  3. KIM KM, PARK JB, BAE KS, KANG SJ. Hungry bone syndrome after parathyroidectomy of a minimally invasive parathyroid carcinoma J Korean Surg Soc [online] 2011 Nov, 81(5):344-349 [viewed 30 September 2014] Available from: doi:10.4174/jkss.2011.81.5.344
  4. GOEPFERT H, SMART CR, ROCHLIN DB. Metastatic parathyroid carcinoma and hormonal chemotherapy. Case report and response to hexestrol. Ann Surg [online] 1966 Nov, 164(5):917-920 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477091