439 Managing Parathyroid Carcinoma in the Age of COVID 19

Aim Parathyroid carcinoma is a rare malignancy accounting for 1% of cases of primary hyperparathyroidism. Pre-operative diagnosis is difficult because in the absence of metastatic disease, the presentation is similar to benign parathyroid disease. In patients with hyperparathyroidism and severe hypercalcaemia or a significantly raised parathyroid hormone (PTH) level clinicians should consider parathyroid carcinoma and expediting surgical management. During the current pandemic, a high index of suspicion should be maintained to ensure that care is not compromised. A review of the management of patients with suspected parathyroid carcinoma during the COVID-19 pandemic is presented. Method In our tertiary referral centre for Endocrine surgery, 4 presentations of parathyroid cancer were reviewed. Their investigations, surgical management and post-operative outcomes are described with a brief literature review of parathyroid cancer. Results Of the four cases of parathyroid carcinoma described, all presented with severe hypercalcaemia and significantly raised PTH levels. Pre-operative mean calcium was 3.36mmol/L and mean PTH was 80pmol/L (52-99.8). Patients were imaged with a combination of cross-sectional imaging and ultrasound. Two patients had evidence of distant disease at presentation. 1 patient was transferred as an inpatient to our centre and the other three patients were seen within 2 weeks of referral; the mean time from referral to surgery was 14days (1-23). Post-operatively, all patients achieved normocalcaemia, with PTH levels normal in all but one. Conclusions Despite limitations on face-to-face clinic consultations and reduced capacity for elective surgery during the COVID-19 pandemic, all patients were investigated and managed promptly to ensure superior outcomes.

Role of LncRNA score and PVT1 in primary hyperparathyroidism-- a preliminary study

Background Dysregulated lncRNA score and PVT1 expression may be involved in cancer. However, relationships of lncRNAs with hyperparathyroidism and parathyroid cancer (PC) diagnosis remain mysterious. Methods Using quantitative real-time polymerase chain reaction (RT-qPCR), expression profile of PVT1 was evaluated in 57 patients with primary hyperparathyroidism, including 11 with parathyroid cancer (PC) and 46 with parathyroid adenoma (PA). Results Higher levels of lncRNA score and PVT1 expression were associated with increased serum calcium level after water ingestion and PC risk (P < 0.05). Accordingly, lncRNA score and PVT1 expression were increased with varying degrees of hypercalcemia in PC. A higher level of lncRNA score (but not PVT1) was an independent risk factor of PC, with an AUC up to 0.872 (95% CI: 0.756–0.945, P < 0.001). Moreover, lncRNA score was more valuable (with AUC 0.974, sensitivity of 85.71% and specificity of 100%, respectively) than intact parathyroid hormone (iPTH) in predicting risk of PC among patients with hypercalcemia (especially based on greater AUC, P = 0.010). Conclusion Increased lncRNA score is correlated with an elevated level of serum calcium, which may serve as a potential biomarker for PC diagnosis, especially with hypercalcemia. Graphical abstract

Debulking surgery for functional pleural dissemination of parathyroid carcinoma-case report

Background A rare cause of primary hyperparathyroidism (PHPT) is a parathyroid carcinoma. Hypercalcemia with an elevated parathyroid hormone (PTH) level seen in recurrent and metastasis disease cases is often refractory to medical therapy, thus surgical resection is recommended when possible. We performed debulking surgery for pleural dissemination of parathyroid cancer for improvement of symptoms in a patient with hypercalcemia. Case presentation A 30-year-old male with hypercalcemia was diagnosed with parathyroid cancer. Following surgery, intact PTH level elevation and hypercalcemia progression due to recurrent disease were noted. An active status of functional left pleural dissemination was revealed in 99mTc-methoxyisobutylisonitrile and somatostatin receptor scintigraphy results, but not in the area of pulmonary metastasis, and debulking surgery was performed. Thereafter, the PTH level was decreased temporarily and activities of daily living improved. Conclusion Aggressive resection of metastatic disease in patients with a parathyroid carcinoma is taken into consideration to control hypercalcemia.

Nonfunctional parathyroid cancer − a case report

Introduction: Parathyroid cancer is a rare endocrine malignancy. These tumors are typically functional, causing severe hypercalcemia due to primary hyperparathyroidism. Nonfunctional parathyroid cancer with normal serum calcium and parathyroid hormone levels is extremely rare. The disease is usually indolent but progressive with a tendency to metastasize. It is very difficult to diagnose this malignancy. The definitive diagnosis is made by histopathological examination. Radical surgery with ipsilateral lobectomy and en bloc neck dissection is considered to be the most appropriate therapeutic approach. There is no evidence of efficiency of adjuvant cancer therapy and its indication has not been defined. Disease recurrence is common. Case report: We report the case of a 26-year-old female patient who underwent left hemithyroidectomy for growth progression of a hypoechoic lesion behind the left thyroid lobe detected by ultrasonography. Preoperative cytology and imaging assessments were not suspicious for malignancy. Serum parathyroid hormone and calcium levels were normal. The diagnosis of nonfunctional parathyroid carcinoma was determined based on histopathological examination. No further surgery or adjuvant therapy was indicated. No signs of recurrence or generalization have been observed at 36 months after the surgery. Conclusion: Nonfunctional parathyroid cancer is extremely rare. In many cases, the diagnosis is made in advanced stages of the disease. No formal classification or treatment protocol has been established so far. A new staging system has been proposed in the 8th edition of AJCC/UICC. Early detection, radical surgery and close follow-up are crucial aspects to affect the mortality and morbidity of patients with this type of malignancy.

Morphometric features of blood vessels in adenomas and carcinomas of the parathyroid gland

In this article discussed the problem of neoangiogenesis in neoplastic processes of the parathyroid gland. Applying morphometric methods for the assessment of sectional tissue samples of patients with adenoma and carcinoma of the parathyroid gland, we obtained the results of quantitative and qualitative vascular growth during neoangiogenesis. At present, there are not many studies that assess vascular factor in parathyroid cancer. This study may be useful in research cancer treatment, as it highlights the pathological aspects of the formation of new blood vessels, which is similar in all malignant processes.

Advances in the diagnosis and the management of primary hyperparathyroidism

The parathyroid glands, one of the last organs to be discovered, are responsible for maintaining calcium homeostasis, and they continue to present the clinician with diagnostic and management challenges that are reviewed herein. Primary hyperparathyroidism (PHPT) comprises the vast majority of pathology of the parathyroid glands. The classic variant, presenting with elevated calcium and parathyroid hormone levels, has been studied extensively, but the current body of literature has added to our understanding of normocalcemic and normohormonal variants of PHPT, as well as syndromic forms of PHPT. All variants can lead to bone loss, kidney stones, declining renal function, and a variety of neurocognitive, gastrointestinal, and musculoskeletal complaints, although the majority of PHPT today is asymptomatic. Surgery remains the definitive treatment for PHPT, and advances in screening, evolving indications for surgery, new imaging modalities, and improvements in intra-operative methods have greatly changed the landscape. Surgery continues to produce excellent results in the hands of an experienced parathyroid surgeon. For those patients who are not candidates for surgery, therapeutic advances in medical management allow for improved control of the hypercalcemic state. Parathyroid cancer is extremely rare; the diagnosis is often made intra-operatively or on final pathology, and recurrence is common. The mainstay of treatment is normalization of serum calcium via surgery and medical adjuncts.