Parathyroid Carcinoma

Case Report
Ihsan Ali Muharom *, Achmad Dimyati**
** Oncology Surgery Division, Surgery Department, Faculty of Medicine
Padjadjaran University / HasanSadikin Hospital, Bandung
* Resident of Surgery Department, Faculty of Medicine
Padjadjaran University / HasanSadikin Hospital, Bandung
ABSTRACT
INTRODUCTION: This case report is intended to describe rare cases,
namely parathyroid carcinoma. Parathyroid tumors are very rare, when
there is usually a carcinoma, approximately 1.5 to 5% of all parathyroid
tumors and is more common in young women, most cases are thought to
be a carcinoma turned out otherwise. Acceptable criteria for malignancy is
the presence of tumor recurrence after removal, distant metastasis or
invasion of adjacent structures, adjacent metastasis, metastasis to the
lungs, liver, bone.
CASE REPORT: A woman, aged 55 years, Mrs.ER, present with a lump in
the neck that come with the right front of swallowing movements, the
newly perceived since six months ago, is not found symptoms of
infiltration into surrounding organs. Since four years ago, there is a lump
in the right lower leg which felt directly by chicken egg. Lumps felt are not
enlarged. Complaints accompanied by lethargy, myalgia and arthralgia
and constipation. No symptoms of bilateral metastasis to regional lymph
nodes, no distant metastases symptoms. Treatment history to
Orthopaedics, suspected tumor metastasis to bone. Then the X-ray
examination cruris with the results of lytic and sclerotic lesions were
bersepta and demarcated in the proximal third right tibia and a few small
ones seen in the middle third of the tibia and fibula and distal; Bone prints
with visible results which increased pathological increase of radioactivity
in bone marrow os proximal tibia dekstra 1/3 and 1/3 medial portion of the
left tibia os; and PET-scan with the results appear enlarged parathyroid
gland with parathyroid adenoma, thereby showing adanaya picture
parathyroid adenoma. Endocrine consulted the IPD patients, performed
FNAB lump in the neck with the results of papillary carcinoma a / r
differential diagnosis of thyroid dekstra with undifferentiated (anaplastic)
thyroid carcinoma and papillary thyroid carcinoma with epidermoid cyst,
then consulted the Surgical Oncology. History dekstra nephrectomy
surgery due to infection of kidney stones in 1990 at RSHS. From the
physical examination found four extremities motor weakness. A / r colli
anterior dekstra there are masses who participated with swallowing
movements, the skin over the same mass with the surrounding skin, firm
boundaries, not Fixed, flat surface, hard consistency, size 1x0,5x0,5cm. A /
r dekstra cruris 1/3 proximal medial aspect there is mass, the skin over
the same mass with the surrounding skin, ill defined, Fixed, flat surface,
hard
consistency,
size
6x4x4cm.
Do
parotidektomi
dekstra,
isthmolobektomi dekstra, frozen section histopathological examination
dekstra parathyroid and thyroid dekstra. Durante the operation, pole

parathyroid tumor mass was found under dekstra yellowish white color,
encapsulated, well defined, 0.3 cm diameter, attached to the lower pole of
thyroid dekstra, exploration of the left thyroid, parathyroid and
parathyroid right upper pole left no abnormalities. From the frozen section
histopathological examination parathyroid and thyroid dekstra, obtained
adenomatous goiter and dekstra parathyroid carcinoma.
Keywords: parathyroid carcinoma
Correspondent:
Ihsan Ali Muharom, MD.
Surgery Department, Faculty of Medicine Padjadjaran University
RSUP dr. Hasan Sadikin Jl. Pasteur No. 38 Bandung
Email: ihsanalimuharom@yahoo.co.id

Parathyroid
Carcinoma

Case Reports
I.

IDENTITY

Name
: Mrs. Euis Rohayatoi
Age
: 55 years
Address
: Kp tile Bandung Barat
Occupation : Housewife
Education
: Elementary School
Inspection Date
: December 10, 2014
II.

History

Main Complaint:
A lump on the right front neck
History Disease Now:
Since 6 months ago new patients aware of a lump in the neck right front part
moves during swallowing of peanuts. Previous since 4 years ago, the patient
complained of a lump in the right lower leg which felt directly by chicken egg.
Lumps felt are not enlarged. Complaints with weak body up can not walk, aches
bone and muscle throughout the body. History CHAPTER noncurrent recognized,
patients admitted BAB once every 4-5 days.
No other bumps in the neck area. No complaints difficult to swallow, with a
history of cough with voice becomes hoarse. No complaints of shortness of breath.
History radiation in the neck area denied. Family history of similar complaints
denied.
Because of the complaint, the patient went to Orthopaedics, said the
possibility of tumor metastasis to bone. Then lower extremity X-ray examination,

bone Sidik and PET-Scan. Endocrine consulted the IPD patients, performed FNAB
lump in the neck, then consulted the Surgical Oncology.
Patients with a history of kidney surgery right kidney stones removed
because of infection tahun1990 at RSHS.

III.

PHYSICAL EXAMINATION

Generalists Status
Awareness: compost mentis
BP: 130/80 mmHg
PR: 80 x / min
RR: 20 x / min
T: 36.8 C
Head: not anemic conjunctiva, sclera no jaundice
Thorax:
Inspection: Movement development symmetric dindingdada
Palpation: Vocal fremitus left = right
Percussion: Sonor, left = right
Auscultation: VBS left = right, Rhonki (- / -), wheezing (- / -)
Heart sounds S1 and S2 regular pure, murmur (-)
Abdomen:
Inspection: Flat, venektasi (-)
Palpation: Soft, nyeritekan (-), defansmuskular (-).

no palpable enlarged liver, spleen not palpable enlarged

Percussion: Timpani, pekaksamping / pekakpindah (- / -)
Auscultation: Bisingusus (+) normal

Extremities: Tremor (-), Motor 4/4, 4/4

Status localist
a / r colli anterior dekstra:
Inspection: Massa who participated with swallowing movements, the skin over the
same mass with the surrounding skin, venektasi (-), hyperemia (-)
Palpation: Mass with distinct borders, not Fixed, flat surface, hard consistency,
moving with the movement, swallowing, NT (-), the size 1x0,5x0,5cm
a / r bilateral colli:
Inspection: not seem lymphadenopathy
Palpation: no palpable lymphadenopathy
a / r dekstra cruris 1/3 proximal medial aspect:
Inspection: Massa, the skin over the same mass with the surrounding skin,
venektasi (-), hyperemia (-)
Palpation: Mass with ill defined, Fixed, flat surface, hard consistency,
NT (-), size 6x4x4cm

Clinical picture:

IV.

RESUME

A woman, aged 55 years, present with a lump in the neck that come with the
right front of swallowing movement. The history shows that the lump is felt since six
months ago, is not found symptoms of infiltration into surrounding organs.
Since four years ago, there is a lump in the right lower leg which felt directly
by chicken egg. Lumps felt are not enlarged. Complaints accompanied by lethargy,
myalgia and arthralgia and constipation.
No symptoms of bilateral metastasis to regional lymph nodes, no distant
metastases symptoms.
Treatment history to Orthopaedics, suspected tumor metastasis to bone. Then
the X-ray examination cruris, Sidik bone and PET-Scan. Endocrine consulted the IPD
patients, performed FNAB lump in the neck, then consulted the Surgical Oncology.
History dekstra nephrectomy surgery due to infection of kidney stones in
1990 at RSHS.
From the physical examination found status obtained generalist motor
weakness four extremities, status localist a / r colli anterior dekstra there are
masses who participated with swallowing movements, the skin over the same mass
with the surrounding skin, venektasi (-), hyperemia (-), well defined, not Fixed, flat
surface, hard consistency, size 1x0,5x0,5cm. a / r dekstra cruris 1/3 proximal medial
aspect there is mass, the skin over the same mass with the surrounding skin,
venektasi (-), hyperemia (-), with defined, Fixed, flat surface, hard consistency, NT
(-) , size 6x4x4cm
V.

DIAGNOSIS

1. Dekstra suspected parathyroid tumor is not malignant infiltration of the

trachea, esophagus, NLR, yet KGB regional metastasis, distant metastasis
unknown
2. Dekstra suspected malignant thyroid tumors that were not infiltrating the
trachea, esophagus, NLR, yet KGB regional metastasis, distant metastasis is
unknown suspect a thyroid carcinoma folikulare
3. Dekstra suspected malignant thyroid tumors that were not infiltrating the
trachea, esophagus, NLR, yet KGB regional metastasis, distant metastasis is
unknown suspect a thyroid carcinoma papilare
VI.

DIAGNOSIS Clinical oncologists

Dekstra suspected parathyroid tumor is not malignant infiltration of the trachea,
esophagus, NLR, yet KGB regional metastasis, distant metastasis unknown

VII.

PRELIMINARY EXAMINATION RESULTS

1. Rontgen cruris Dekstra
Lytic and sclerotic lesions were bersepta and demarcated in the proximal third
right tibia and a few small ones seen in the middle third of the tibia and fibula
and distal.

2. Fingerprint Bone (06/18/2014): Looks increase in radioactivity which

increased pathological bone marrow os proximal tibia dekstra 1/3 and 1/3
medial portion of the left tibia os.
3. PET scan (6/10/14): Looks enlarged parathyroid gland with parathyroid
adenoma. Thus picture showed parathyroid adenoma adanaya
4. FNAB (F.141170) 08/20/2014:
Thyroid FNAB dekstra: necrotic mass mixed with blood
Preparations aspiration biopsy consists of necrotic masses and colloids. Cells
appear round shape, oval which group preparing follicles, papillary and

monolayer, partly dispersed. Round cell nuclei, coarse chromatin, forming the
core portion pseudoinklusion structure and little cytoplasm. It also seems
superficial squamous cells that spread to the core rather large, polimorfi,
chromatin is rather rough.
Conclusions:
Papillary Carcinoma a / r Thyroid dextra dd / undifferentiated (anaplastic)
carcinoma, thyroid carcinoma papilary with epidermoid cyst.
VIII.

IX.

EXAMINATION OF PROPOSED PENUNJAN G

1. Calcium serum
1 Serum phosphate
2 Parathyroid hormone (PTH)
3 Thyroid function tests
4 Thyroid ultrasound and bilateral colli
5 Thorax Photos
DIAGNOSIS SUPPORT
Serum Calcium: 5.99
Serum phosphate: no results
PTH: no results
Thyroid Function Tests
T3 = 1,9nmol / L
FT4 = 0,1ng / dL
TSHs = 0.6 IU / mL
5. Thyroid ultrasound and bilateral colli
Right intrathyroid cystic nodules with calcification suggestive of a parathyroid
adenoma dd / thyroid nodules, thyroid left this time does not seem kelianan,
does not seem lymphadenopathy bilateral colli
1.
2.
3.
4.

6. Thorax Photos
Looks intrapulmonary metastasis

X.

THERAPY

Parathyroidektomi dekstra
Isthmolobektomi dekstra
Histopathologic examination of the frozen section

Durante operation (12/18/2014), found:

Under the pole parathyroid tumor mass dekstra yellowish white color,
encapsulated, well defined, 0.3 cm diameter, attached to the bottom pole
thyroid dekstra
Exploration of the left thyroid, parathyroid and parathyroid right upper pole
left no abnormalities.
Frozen section histopathological examination parathyroid and thyroid dekstra,
obtained adenomatous goiter and dekstra parathyroid carcinoma.

DISCUSSION
Parathyroid glands
These glands produce parathyroid hormone and calcitonin that play a role in
the metabolism of calcium and phosphorus. Glandular secretion is regulated by the
level of calcium in the kidney tubules, decreased levels of parathormone and
calcitonin plasma will lead to heightened reabsorption of calcium from bone and
kidney tubules, causing an increase in plasma calcium.

PHYSIOLOGY

HYPERPARATHYROIDISME
A situation where the production of primary elevated parathormone secretion
increases whereas if the secondary when production increases due to the need.
Primary Hyperparathyroid caused a parathyroid adenoma which can lead to a state
of fibrous Osteitis Kistika. In the X-ray picture of thinning bones appear
accompanied by the formation of multiple cysts that, and often fracture patalogis,
which normally occur in the bone plate, pelvis and skull. Urinary tract stones are
often due to high plasma calcium levels.
Secondary Hyperparathyroid occurs because parathyroid gland hyperplasia
and hypertrophy due to kidney disease, multiple myeloma, metastatic carcinoma to
the bone, Paget's disease and osteogenesis imperfecta.

Neoplasms
Very rarely, when there is usually a carcinoma, approximately 1.5 to 5% of all
parathyroid tumors and is more common in young women, most cases are thought
to be a carcinoma turned out otherwise. Acceptable criteria for malignancy is the
presence of tumor recurrence after removal, distant metastases or invasion of
adjacent structures, metastases adjacent, could metastases to the lungs, liver,
bone.

KEY POINTS
1. Focused mini-incision Parathyroidectomy, having known with certainty its
location to be chosen procedure for the handling of primary
hyperparathyroidism.
2. Parathyroidectomy can improve symptoms and metabolic complications of
primary hyperparathyroidism.
3. Calcium levels and high parathyroid hormone suspected parathyroid
carcinoma.

BIBLIOGRAPHY
1. Acosta, Jose. et al., Chapter 36 - Thyroid and Chapter 37 - The Parathyroid
Gland. In Sabiston DC, Text Book of Surgery, 1 8 th ed, WB Saunders,
Philadelphia, 2008.
2. Regato JA, del Regato 's. Cancer Diagnosis Treatment and Prognosis, 6 th ed,
The CV Mosby Co., Toronto, 1985, pp 425-443
3. Brunicardi, F. Charles. et al. Chapter 38 - Thyroid, Parathyroid, and Adrenal. In
Scwartz's Principles of Surgery, 9 th ed, International Edition, Mc Graw Hill
International Book. 2010.
4. Sadler, TW et al., Chapter 16 - Head & Neck. In Langman's Medical
Embryology 10 th edition by Vishal. Maryland Composition Co. Inc. 2009.
5. Kumar V, Cotran RS, Robbins. The Endocrine System:
Parathyroid. In ROBBINS BASIC Pathology, 7ED, Elsevier. 2007.

Thyroid

and