Effective long-term management of parathyromatosis-related refractory hypercalcemia with a combination of denosumab and cinacalcet treatment.

Parathyromatosis is a rare cause of persistent or recurrent primary hyperparathyroidism and hypercalcemia due to the presence of hyperfunctioning foci of parathyroid tissue in the neck and/or mediastinum. We describe the case of a male patient who presented with severe hypercalcemia and a left-sided palpable parathyroid mass. Over the course of the next 18 years, the patient underwent neck exploration surgery on multiple occasions due to recurrent primary hyperparathyroidism and refractory hypercalcemia, complicated by nephrolithiasis and impairment of renal function, while bone mineral density was preserved. Histological findings and the natural course of the disease were consistent with parathyromatosis. Medical interventions with oral bisphosphonates or high-dose cinacalcet failed to control the patient's hypercalcemia. The combination of monthly denosumab and cinacalcet was, however, successful in maintaining the patient's serum calcium in the normal/upper-normal range over a 36-month period with no significant side effects. This is the first report of off-label denosumab use in combination with cinacalcet in the long-term management of parathyromatosis-related refractory hypercalcemia.

Recombinant human thyrotropin-aided radioiodine therapy in tracheal obstruction by an invading well-differentiated thyroid carcinoma.

Papillary thyroid carcinomas (PTCs) usually extend to lymph nodes in the neck and mediastinum. Rarely, they invade the neighboring upper airway anatomical structures. We report a 56-year-old woman who presented with symptoms of upper airway obstruction. Imaging studies revealed a lesion derived from the thyroid which invaded and obstructed the trachea, which appeared to be a highly differentiated PTC. Total thyroidectomy was performed, with removal of the endotracheal part of the mass along with the corresponding anterior tracheal rings. Two months later, a whole body I(131) scan after recombinant human thyroid-stimulating hormone (rh-TSH) administration was performed and revealed a residual mass in upper left thyroid lobe. Subsequently, 150 mCi I(131) were given following rh-TSH administration. Nine months later, there was no sign of residual tumor. This case is the first one reported in the literature regarding rh-TSH administration prior to RAI ablation in a PTC obstructing the trachea.

Value of the cervical compartments in the surgical treatment of papillary thyroid carcinoma.

In the treatment of papillary thyroid carcinoma (PTC), supplementary lymph node dissection (LND) is not well standardized. The purpose of this study was to evaluate the significance of the cervical compartments in the lymphatic spread of PTC and the impact of modified radical neck dissection (MRND) as an additional surgical procedure to thyroid resection. From 1999 to 2002, LND of the central compartment (compartment A) was performed in 39 patients. Among this group, additional MRND of the ipsilateral compartment (compartment B) and the contralateral compartment (compartment C) was performed in 29 and 15 patients respectively, who met the selection criteria. The mean number of nodes resected was 11 (5-22) in compartment A, 23 (8-37) in compartment B, and 22 (10-31) in compartment C. Histopathologic findings revealed node invasion of compartment A in 25 patients (64.1%), of A and B in 20 patients (51,2%) and of A, B, and C in 13 patients (33.3%). From the 25 patients with metastases in compartment A, 80% (20 patients) already had metastases in compartment B and 52% (13 patients) had metastases in all three compartments. All patients free of metastasis (M0) in compartment A were also metastasis free in both lateral compartments. Postoperative whole-body scanning I(131) in M0 patients showed no uptake at all. Mapping of the cervical anatomy in compartments seems to be a useful taxonomy for clarifying the lymphatic spread of PTC. Patients having PTC without metastasis in compartment A are almost certainly disease free at the time of operation. Lymph node metastasis in the central compartment appears to be a valuable indicator of lymphatic invasion of the lateral compartment and a strong indication for performance of a unilateral or bilateral MRND to complete the surgical removal of tumor.