Delayed diagnosis of parathyroid cancer manifested with pubic bone lesions and chronic kidney failure. Tricks and pitfalls of management.

INTRODUCTION: Parathyroid cancer (PTC) is an extremely rare malignancy with an incidence of 5.7 per 10 million people. The exact preoperative or intraoperative diagnosis is difficult, but of paramount importance, because resection with negative margins is the only effective treatment. CASE REPORT: A 46-years-old female was referred from another hospital with a diagnosis of "hyper-functioning thyroid nodule", based on the ultrasound showing a lesion of the right thyroid lobe and elevated FT4. At the admission, she had severe pain in the right inguinal area, fatigue, muscle weakness, and excessive diuresis. The blood assay demonstrated serum calcium of 4.02 mmol/l, parathyroid hormone of 1433.2 pg/ml, FT4 of 17.49 pmol/l, creatinine of 296 µmol/l. CT showed a tumor of the right thyroid lobe with a size of 2.5. A right lobectomy was performed. Right parathyroid glands were not found. Because of the constellation for hyperparathyroidism and suspicion of parathyroid malignancy ipsilateral and central lymph node dissection and partial removal of the right sternothyroid muscle were performed, which correlated with a significant intraoperative drop in the parathyroid hormone. Three months later, a re-resection was performed because of SPECT-CT evidence for residual parathyroid tissue. CONCLUSION: The timely diagnosis of PTC is a prerequisite for a good outcome. The best preoperative indicators are serum parathyroid hormone > 4 times above the upper limit, serum calcium > 14 mg/dL, a palpable neck mass, and a local invasion found intraoperatively. The only curative treatment is the complete removal of the tumor with a negative margin. KEY WORDS: Delayed diagnosis, Hyperparathyroidism, Parathyroid cancer, Surgery.

A Unique Complication after a Routine Operation - Late Pseudoaneurysm of the Brachial Artery after Plate Fixation of Humeral Shaft Fracture. A Case Report and Review of the Literature.

We report an extremely rare case of an 82-year-old woman with pseudoaneurysm of the brachial artery developed 22 months after a plate osteosynthesis with angularly stable locking plates for the proximal humerus. The condition was initially misdiagnosed as a tumor by the attending physician, and the patient was referred to an oncological unit. The case was successfully managed by a multidisciplinary team consisting of orthopedic and vascular surgeons.An up-to-date review of the available literature is also provided. The pseudo-aneurysms of the axillary and the distal peripheral arteries of the upper limb are a rare but potentially dangerous complication because the thromboembolism could lead to gangrene and amputation of the extremity. Despite casuistic, they should be taken into consideration in the differential diagnosis after plate osteosynthesis. Proper operative technique and constant vigilance when orthopedic implants are used are of paramount importance, which is actually the emphasis of this report.