Parathyroid Carcinoma Research Articles

Parathyroid Carcinoma - A Tertiary Centre's Experience Over 15 Years.

Parathyroid Carcinoma - A Tertiary Centre's Experience Over 15 Years.

The polar vessel sign: insights from CT imaging analysis in Asian Indian primary hyperparathyroidism.

Data on the polar vessel sign (enlarged feeding vessel terminating in parathyroid lesions) on four-dimensional computed tomography (4D-CT) is limited. We performed a retrospective analysis to determine the prevalence, predictors, and adjunctive utility of polar vessel sign in pre-operative 4D-CT of patients with primary hyperparathyroidism (PHPT). One radiologist blinded to the patients' details reported the 4D-CT of eighty-four operated patients with histopathology-proven single-gland PHPT. Two protocols were used to obtain arterial-phase images: timed via bolus tracking (n = 41) or fixed at 20 s after contrast injection (n = 43). Seventy-one patients were symptomatic for PHPT, with median serum calcium 12.1 mg/dL. On the arterial phase of 4D-CT, 88.1% of lesions had the polar vessel sign, including 7/9 asymptomatic patients, 6/6 parathyroid carcinomas, and 3/4 ectopic(1:mediastinum, 2:thyro-thymic ligament). Predictors of polar vessel sign were maximum lesion dimension (2.2 vs. 1.4 cm; P = 0.03), solid-cystic CT morphology (47.3% vs. none; P = 0.004), and bolus tracking-timed arterial phase (55.4% vs. none; P = 0.001). Of these, bolus tracking improved the polar vessel's visualization (100% vs. 76.7%; P = 0.001) independent of lesion dimension and solid-cystic morphology. The latter two predicted polar vessel sign in images obtained at a fixed interval (20 s). A significantly lower proportion of bolus tracking-timed scans had lesion percentage arterial enhancement (PAE) < 128.9% (2/41 vs. 9/43; P = 0.04). Even with suboptimal PAE, the polar vessel helped identify 9/11 lesions. The polar vessel sign demonstrated an additive role to PAE during CT reporting. Bolus tracking is valuable in optimizing vessel and tumor arterial enhancement and is easily incorporated into parathyroid 4D-CT protocol.

The challenge of the differential diagnosis between brown tumors and metastases in parathyroid carcinoma: a case report

The challenge of the differential diagnosis between brown tumors and metastases in parathyroid carcinoma: a case report

Rebound hypercalcemia after denosumab cessation during follow-up after surgical treatment for parathyroid carcinoma: case report and literature review

Rebound hypercalcemia after denosumab cessation during follow-up after surgical treatment for parathyroid carcinoma: case report and literature review

Parathyroid carcinoma: molecular pathology and correlation with clinicopathologic features, a single center experience

Abstract Introduction/Objective Parathyroid Carcinomas are rare malignant neoplasms, accounting for less than 1% of primary hyperparathyroidism cases. Parathyroid carcinomas are characterized by markedly elevated levels of PTH, severe hypercalcemia and established target organ damage. The authors report the experience of a single center regarding the clinic-pathologic and genetic analysis of parathyroid carcinoma cases. Methods/Case Report The study is a retrospective review of all patients with parathyroid carcinoma that were evaluated at a tertiary oncologic center from 2001 until 2023. Results (if a Case Study enter NA) A total of nine cases (6 male and 3 female) were identified, with a mean age at diagnosis of 52 ± 16 years and a median follow-up of 16.5 years. Most patients presented with hypercalcemia (n = 7), with a mean serum calcium concentration of 13.5 mg/dl (9.6-16.5) and a mean PTH of 1123 pg/ml (&amp;lt;a href=“tel:276- 2500”&amp;gt;276-2500&amp;lt;/a&amp;gt;). En bloc surgical resection was performed in 6 patients and 3 patients underwent adjuvant radiotherapy. Recurrence was observed in 4 cases (44.4%) after a median of 24 months following surgery. Negative immunohistochemical staining of parafibromin was noted in 3/4 cases of recurrence. Parathyroid carcinoma was diagnosed on the basis of finding lesions with vascular or perineural invasion, capsular penetration, and/or documented metastases. Immunohistochemical staining for parafibromin, Ki-67, and E-cadherin was performed on formalin-fixed, paraffin-embedded tissue samples. Next generation sequencing (NGS) was performed in 6/9 cases and CDC73 mutations were present in 38.5% of analyzed patients. Loss of TP53 and RB1 alleles and CCND1 amplification were other reported genetic alterations in the study cohort. Conclusion Parathyroid carcinoma is associated with a significant rate of recurrence and limited effective treatment beyond initial complete surgical resection. Inactivating CDC73 alterations which include truncating or frameshift mutations, as well as missense mutations lead to the loss of parafibromin immunoreactivity. Other molecular alterations like PTEN and PIK3CA mutations may represent potential targets for molecular therapy. An IHC panel of parafibromin, Ki-67 and E-cadherin may help to distinguish parathyroid carcinoma from other parathyroid neoplasms.

Cohort review of patients with parathyroid cancer in End Stage Renal Disease (ESRD).

Parathyroid carcinoma (PTTC) is a rare malignant endocrine tumor seen in up to 1-2% of all cases of primary hyperparathyroidism. However, incidence of parathyroid carcinoma in renal hyperparathyroidism is a rare phenomenon. We aimed to evaluate the outcomes of PTTC in renal hyperparathyroidism published in the literature. Cohort review of parathyroid cancer cases reported in Medline (via PubMed), COCHRANE and EMBASE between the period 1985 - 2023 in patients with renal hyperparathyroidism. A total of 48 patients (20M: 28F), with a mean age of 49.8 (± 11.7 SD: range 20-75) years. Dialysis vintage was for a period of 8.9 (± 7.2; range 6months to 40years). The mean preoperative values were as follows: serum corrected calcium-2.87 IQR 2.56-3.01), PTH - 221.8 (IQR 86.6 -257.2pmol/L) and serum phosphate - 2.07 (IQR 1.72-2.28) mmol/L. Preoperative imaging was in the form of ultrasound of the neck in 21 of 48 (44%), MIBI scan in 27/48 (56%), contrast enhanced computerized tomography in 14/48 (29%) and MRI neck in 1/48 (2%). The mean size of the cancer was 2.7 (± 1.35) cm and weight of the gland ranged between 0.9 to 4.98g. 18/48 (37%) patients underwent a total parathyroidectomy and 30/48 (63%) had subtotal parathyroidectomy. En bloc excision of the tumour along with the thyroid along and central compartment lymph nodes was only performed in 12/48 (25%), of whom 9 (19%) had it performed at index surgery, whereas in the rest was done for persistent or recurrent disease. After a mean follow up of 34months, 14 (29%) had local recurrence, 1 (2%) had distant metastasis to the skeletal system, and 12 (25%) to the lungs. Cohort mortality was 6 (13%) due to refractory hypercalcemia. Parathyroid carcinoma in renal hyperparathyroidism is rare but when encountered, en bloc excision with parathyroidectomy provides the best chance of cure. Recurrences can be difficult to treat but may be needed to treat intractable hypercalcaemia.

12312 A Comparative Genomic Analysis Between Parathyroid Adenomas And Carcinomas With Heterozygous Germline Cdc73 Mutations

Abstract Disclosure: Y. Li: None. W.F. Simonds: None. H. Chen: None. Introduction: Parathyroid cancer is responsible for ∼1% of primary hyperparathyroidism. The hereditary form of this malignancy has been linked to germline mutations of the CDC73 gene. We previously reported that only the germline CDC73 mutations causing a significant impact on the function/expression of its encoded protein are associated with parathyroid carcinomas. On the other hand, these germline mutations may lead to only parathyroid adenomas or no parathyroid disease, suggesting incomplete penetrance. This observation raises the question of what additional genomic events are required for parathyroid tumorigenesis in carriers with germline CDC73 mutations. Methods: Twelve patients harboring heterozygous germline CDC73 mutations were included in this study. Whole exome sequencing was performed in all 12 parathyroid tumors (6 adenomas and 6 carcinomas) and the paired normal tissues. RNA sequencing was successfully performed in three of each parathyroid carcinomas, adenomas, and normal glands. The sequencing raw data were processed using the CCBR-Pipeliner. EnrichR, Gene Set Enrichment Analysis, and CIBERSORT were used for the downstream analyses. Results: All parathyroid carcinomas and adenomas had gained one somatic event predicted to cause a complete inactivation of the second CDC73 allele. Several distinctive genomic features were identified in parathyroid carcinomas compared to adenomas, including more single nucleotide variants bearing the signature of APOBEC deamination, frequent mutations among the genes involved in the PI-3K/mTOR signaling, and substantially more copy number variations and differentially expressed genes. Parathyroid carcinomas also share some genomic features with adenomas. For instance, both tumors have frequent somatic mutations and copy number loss that impact the genes related to T-cell receptor signaling and tumor antigen presentation, suggesting a shared strategy to evade immune surveillance. Consistent with these findings, an in silico estimation of immune cell composition in tumors found an absence of CD8+ T-cells in parathyroid adenomas and carcinomas. Conclusion: Our study provides evidence that biallelic inactivation of CDC73 is essential for parathyroid tumorigenesis in carriers with germline mutations of this gene. Despite sharing some genomic features with adenomas, parathyroid carcinomas have more distinctive alterations in the genome, some of which may be critical for cancer formation. Presentation: 6/2/2024

12312 A Comparative Genomic Analysis Between Parathyroid Adenomas And Carcinomas With Heterozygous Germline Cdc73 Mutations

Abstract Disclosure: Y. Li: None. W.F. Simonds: None. H. Chen: None. Introduction: Parathyroid cancer is responsible for ∼1% of primary hyperparathyroidism. The hereditary form of this malignancy has been linked to germline mutations of the CDC73 gene. We previously reported that only the germline CDC73 mutations causing a significant impact on the function/expression of its encoded protein are associated with parathyroid carcinomas. On the other hand, these germline mutations may lead to only parathyroid adenomas or no parathyroid disease, suggesting incomplete penetrance. This observation raises the question of what additional genomic events are required for parathyroid tumorigenesis in carriers with germline CDC73 mutations. Methods: Twelve patients harboring heterozygous germline CDC73 mutations were included in this study. Whole exome sequencing was performed in all 12 parathyroid tumors (6 adenomas and 6 carcinomas) and the paired normal tissues. RNA sequencing was successfully performed in three of each parathyroid carcinomas, adenomas, and normal glands. The sequencing raw data were processed using the CCBR-Pipeliner. EnrichR, Gene Set Enrichment Analysis, and CIBERSORT were used for the downstream analyses. Results: All parathyroid carcinomas and adenomas had gained one somatic event predicted to cause a complete inactivation of the second CDC73 allele. Several distinctive genomic features were identified in parathyroid carcinomas compared to adenomas, including more single nucleotide variants bearing the signature of APOBEC deamination, frequent mutations among the genes involved in the PI-3K/mTOR signaling, and substantially more copy number variations and differentially expressed genes. Parathyroid carcinomas also share some genomic features with adenomas. For instance, both tumors have frequent somatic mutations and copy number loss that impact the genes related to T-cell receptor signaling and tumor antigen presentation, suggesting a shared strategy to evade immune surveillance. Consistent with these findings, an in silico estimation of immune cell composition in tumors found an absence of CD8+ T-cells in parathyroid adenomas and carcinomas. Conclusion: Our study provides evidence that biallelic inactivation of CDC73 is essential for parathyroid tumorigenesis in carriers with germline mutations of this gene. Despite sharing some genomic features with adenomas, parathyroid carcinomas have more distinctive alterations in the genome, some of which may be critical for cancer formation. Presentation: 6/2/2024

7254 An Unusual Case Of Hypercalcemia

Abstract Disclosure: S. Shushtarian: None. M. Balogun: None. T. Kaur: None. Hypercalcemia varies depending on severity. Higher serum calcium levels and more severe symptoms may indicate primary hyperparathyroidism or a malignant cancer. This is a case of a 32 year old female who presented with recurrent history of nephrolithiasis, found to have hypercalcemia of 13.4 mg/dL and parathyroid hormone of 1928.9 pg/mL, with phosphorus of 1.5 mg/dL. Ultrasound of her thyroid revealed a complex nodule arising from the right parathyroid gland measuring 2.2 X 2.0 cm. CT chest revealed diffuse osseous sclerosis secondary to metabolic disorder. Sestamibi scan did not localize any parathyroid adenoma. MRI of the thoracic and lumbar spine showed multiple small enhancing lesions throughout the pelvis and in the left rib, likely brown tumors related to hyperparathyroidism. X-ray of bony prominence on the patient’s left knee revealed a large lytic lesion of the proximal tibial diaphysis measuring 5.1 X 1.9 cm, concerning for aggressive neoplasm. Subsequent left tibial bone biopsy revealed giant cell rich lesions consistent with brown tumor of hyperparathyroidism. Due to our patient’s high calcium levels and large nodule size, she was referred to a tertiary center as the concern for parathyroid carcinoma and post-op hungry bone syndrome was high. Pre-op PTH level was 1408 pg/mL and post-op PTH was 96 pg/mL. The tumor removed was 2.1 cm. Post surgical pathology was consistent with atypical parathyroid adenoma. Patient was referred for genetic testing. An atypical parathyroid adenoma (APA) only accounts for 1.2 to 1.3% of cases of primary hyperparathyroidism. 80-85% of primary hyperparathyroidism is due to typical adenoma, and 10 to 15% of cases are due to hyperplasia or multiple gland disease. APA can often be confused with parathyroid carcinoma (PC), as they both have a 1:1 male to female ratio, high serum calcium levels, symptomatic hypercalcemia, high PTH levels, and fragility fractures. There are studies showing that both APA and PC have loss of nuclear parafibromin immunoreactivity. In addition, neither APA nor PC have any correlation with menopause, hormones, or gene deletions, unlike typical adenomas. Biopsy is necessary for diagnosis as the histological and immunohistochemical differences can differentiate APA vs PC. Histological features include pseudo-capsular invasion, bands of fibrosis, pronounced trabecular growth, nuclear atypia, and prominent nucleoli. Also, APA has a strong membranous staining pattern of E-cadherin, whereas PC has a loss of membranous staining. These differences are essential as although APA and PC clinically present similarly, APA lacks the invasive growth and possibility for metastatic disease that PC has. The likelihood for relapse of APA is low. Presence of malignancy criteria are indicative that a mass is actually PC and not APA. Despite this, APA is still considered a tumor of uncertain malignant potential and requires follow up. Presentation: 6/3/2024

7388 Rare Case of Mediastinal Parathyroid Carcinoma

Abstract Disclosure: Y. Esaki: None. J. Moalem: None. A. Israel: None. I. Shafiq: None. Introduction: Parathyroid carcinoma accounts for 1% of primary hyperparathyroidism with an estimated prevalence of 0.005% of all cancers. Ectopic locations of parathyroid tumors have been found in 6-16% of cases, most commonly in the thyroid, the thymus, or behind the esophagus. Parathyroid carcinoma is rarely found in the mediastinum and only 30 cases have been reported in the literature. Clinical Case: A 68-year-old male without significant past medical history was evaluated by his primary care physician for constipation, polyuria and 20 lb weight loss over the past year. He presented to the hospital after blood work revealed serum calcium of 13.5 mg/dl (8.6-10.2 mg/dl). Initial hospital workup demonstrated serum calcium 12.9 mg/dl, phosphorus 2.6 mg/dl (2.7-4.5 mg/dl), 25-OH vitamin D 21 ng/ml (30-60 ng/ml), 1,25-(OH)2 vitamin D 143.0 pg/ml (19.9-79.3 pg/ml), PTH-related protein &amp;lt; 2.0 pmol/L (0.0-2.3 pmol/L) and PTH 1,250.0 pg/ml (15.0-65.0 pg/ml). CT scan revealed a 3.5 cm x 2.6 cm heterogeneous right paratracheal soft tissue mass with areas of calcifications with mass effect on SVC. Thyroid ultrasound showed multinodular thyroid tissues with a left 1.1 cm heterogeneous solid nodule along the mid posterior aspect as well as a 0.5 cm hypoechoic lesion inferior to the left lobe. Sestamibi scan demonstrated a large area of increased uptake corresponding to the mass seen in the superior mediastinum on CT imaging. He underwent neck exploration and left hemithyroidectomy as well as median sternotomy with resection of the paratracheal mass. Intraoperative PTH decreased from the baseline of 1,177.0 pg/ml to 65.6pg/ml following the removal of the paratracheal mass. The final pathology of right anterior mediastinal mass was consistent with a 5 cm parathyroid carcinoma with angioinvasion, intermediate lymphatic invasion, invasion into adjacent structures, and Ki67 proliferative index focally &amp;gt; 5%. His post-operative course was complicated by hypocalcemia, which improved with treatment with calcitriol and calcium supplementation. He declined the genetic testing. His calcium and parathyroid hormone have remained in the normal range after 1 year. Conclusion: This case illustrates a rare case of parathyroid carcinoma found in the mediastinum. It is important to recognize that parathyroid carcinoma can present in ectopic locations including the mediastinum, as this can affect the preoperative investigation and management. Fine needle biopsy (FNA) prior to the initial operation is not recommended as it is difficult to differentiate the parathyroid carcinoma from benign disease based on FNA, and it may cause tumor rupture and seeding. Also, in the mediastinal parathyroid carcinoma, localization of the lesions including the size and invasiveness is critical in order to allow for radical surgery. Presentation: 6/3/2024

8592 Parathyroid Carcinoma: A Rare Cause of Primary Hyperparathyroidism

Abstract Disclosure: S.E. Koshy: None. C.F. Mulcahy: None. P.S. Kothari: None. E.M. Jacobi: None. T.D. Cubb: None. Introduction: Parathyroid carcinoma (PC) is a rare malignancy that accounts for &amp;lt;1% of cases of primary hyperparathyroidism (PHPT). Patients often present with symptoms of hypercalcemia, serum calcium (Ca) &amp;gt;14 mg/dL, large tumor size, and a very high parathyroid hormone (PTH) level. We report a case of an asymptomatic patient with incidentally found hypercalcemia consistent with PHPT who was ultimately diagnosed with PC. Clinical Case: A 31yo male was found to have elevated serum Ca of 12.7 mg/dL (8.6-10.3 mg/dL) on labs obtained during routine physical exam. He had no known significant medical or family history and notably had no laboratory evaluation within the prior 10 years. He denied constipation, polyuria, confusion, depression, bone pain, and history of fractures or nephrolithiasis. Workup showed an inappropriately elevated PTH of 505 pg/mL (16-77 pg/mL). Neck ultrasound demonstrated a left inferior 3.9 cm complex thyroid nodule. Sestamibi scan confirmed increased uptake in the inferior left thyroid. Left neck exploration was performed. Intraoperatively, a 3.7 cm left parathyroid mass weighing 13.0 grams was encountered and excised in an en bloc fashion. The left superior parathyroid gland was evaluated and found to be normal. Intraoperative PTH level decreased from 529 pg/mL to 48 pg/mL 10 minutes after excision. Left hemithyroidectomy was not performed. Surgical pathology revealed PC with lymphovascular invasion, suspected capsular invasion, and negative margins. Immunohistochemical staining showed a Ki67 proliferation index up to 5% and complete loss of nuclear staining for parafibromin. Next generation sequencing demonstrated a somatic CDC73 p.L8fs mutation, tumor mutational burden 4.7m/MB, and stable microsatellite instability. Germline testing was negative for a CDC73 mutation. Postoperative staging did not demonstrate evidence of metastatic disease in the neck or chest. Serum Ca remained within normal limits. After multidisciplinary discussion, no further surgical intervention was recommended and plan was for ongoing biochemical and imaging surveillance. Conclusion: Though rare, PC should be considered as a cause of PHPT. The primary treatment is complete surgical resection. Unfortunately, there is a high rate of recurrence, &amp;gt;50%, with most occurring 2-5 years after initial surgery with a median overall survival of 14 years. Thus, long-term surveillance is of utmost importance. Treatment of recurrent disease is surgical resection when feasible as well as medical management of hypercalcemia. Further research is needed to better understand the role of targeted systemic therapy in addition to immunotherapy. PC is most commonly sporadic but can be hereditary, thus genetic evaluation is recommended. Given its rarity and complexity, PC is best managed in a multidisciplinary setting. Presentation: 6/1/2024

8592 Parathyroid Carcinoma: A Rare Cause of Primary Hyperparathyroidism

Abstract Disclosure: S.E. Koshy: None. C.F. Mulcahy: None. P.S. Kothari: None. E.M. Jacobi: None. T.D. Cubb: None. Introduction: Parathyroid carcinoma (PC) is a rare malignancy that accounts for &amp;lt;1% of cases of primary hyperparathyroidism (PHPT). Patients often present with symptoms of hypercalcemia, serum calcium (Ca) &amp;gt;14 mg/dL, large tumor size, and a very high parathyroid hormone (PTH) level. We report a case of an asymptomatic patient with incidentally found hypercalcemia consistent with PHPT who was ultimately diagnosed with PC. Clinical Case: A 31yo male was found to have elevated serum Ca of 12.7 mg/dL (8.6-10.3 mg/dL) on labs obtained during routine physical exam. He had no known significant medical or family history and notably had no laboratory evaluation within the prior 10 years. He denied constipation, polyuria, confusion, depression, bone pain, and history of fractures or nephrolithiasis. Workup showed an inappropriately elevated PTH of 505 pg/mL (16-77 pg/mL). Neck ultrasound demonstrated a left inferior 3.9 cm complex thyroid nodule. Sestamibi scan confirmed increased uptake in the inferior left thyroid. Left neck exploration was performed. Intraoperatively, a 3.7 cm left parathyroid mass weighing 13.0 grams was encountered and excised in an en bloc fashion. The left superior parathyroid gland was evaluated and found to be normal. Intraoperative PTH level decreased from 529 pg/mL to 48 pg/mL 10 minutes after excision. Left hemithyroidectomy was not performed. Surgical pathology revealed PC with lymphovascular invasion, suspected capsular invasion, and negative margins. Immunohistochemical staining showed a Ki67 proliferation index up to 5% and complete loss of nuclear staining for parafibromin. Next generation sequencing demonstrated a somatic CDC73 p.L8fs mutation, tumor mutational burden 4.7m/MB, and stable microsatellite instability. Germline testing was negative for a CDC73 mutation. Postoperative staging did not demonstrate evidence of metastatic disease in the neck or chest. Serum Ca remained within normal limits. After multidisciplinary discussion, no further surgical intervention was recommended and plan was for ongoing biochemical and imaging surveillance. Conclusion: Though rare, PC should be considered as a cause of PHPT. The primary treatment is complete surgical resection. Unfortunately, there is a high rate of recurrence, &amp;gt;50%, with most occurring 2-5 years after initial surgery with a median overall survival of 14 years. Thus, long-term surveillance is of utmost importance. Treatment of recurrent disease is surgical resection when feasible as well as medical management of hypercalcemia. Further research is needed to better understand the role of targeted systemic therapy in addition to immunotherapy. PC is most commonly sporadic but can be hereditary, thus genetic evaluation is recommended. Given its rarity and complexity, PC is best managed in a multidisciplinary setting. Presentation: 6/1/2024

7508 Primary Hyperparathyroidism Caused By A CDC73-related Atypical Parathyroid Tumor

Abstract Disclosure: R. Cardenas: None. S. Tariq: None. R. Habibi: None. N. Ebrahimi: None. E. Astiazaran-Symonds: None. Background: Primary hyperparathyroidism (PHPT) is a common endocrine disease, causes include: parathyroid adenomas (80-85%), parathyroid hyperplasia (10-15%), atypical parathyroid adenomas (APA) (1.2 %) and parathyroid carcinomas (PC) (1%). APA share many anatomic and histopathologic features with PC making the distinction between the two challenging. Although most are sporadic, some APA are caused by germline mutations in the CDC73 gene, which is associated with hyperparathyroidism-jaw tumor (HPT-JT) syndrome PC and familial isolated PHPT with APA. Clinical Case: A 42-year-old female presented to the clinic for evaluation of recurrent PHPT. She was diagnosed at age 22 when she experienced fatigue, polydipsia with hypercalcemia (12.9mg/dl). She underwent superior bilateral parathyroidectomy with pathology consistent with parathyroid adenoma. Twenty years later, symptoms recurred and tests showed hypercalcemia (13.0 mg/dl), elevated PTH (252 pg/dl), kidney function preserved (GFR: 82.5 ml/min), normal vitamin D 25 OH (31 ng/dl). Patient denied history of nephrolithiasis or fractures. Family history was positive for kidney stones in father and siblings, also history of a jaw tumor in niece. Sestamibi scan showed a left inferior parathyroid adenoma. Patient underwent resection of the adenoma; pathology revealed a left parathyroid adenoma with atypical parathyroid tumor, &amp;gt;95% cellularity with cytologic features concerning for malignancy, prominent macronucleoli, necrosis, elevated mitotic activity and Ki67 with 15% tumor cells without vascular invasion. Post-op Calcium and PTH normalized (9.6 mg/dl and 10.8 pg/ml, respectively). Genetic testing via multi-gene panel identified a whole gene deletion of CDC73, consistent with hyperparathyroidism-jaw tumor syndrome. Panoramic jaw x-rays did not show jaw tumors. Genetic testing for family members is underway. Conclusion: Although somatic mutations in CDC73 are frequently found in sporadic APA and PC, germline mutations are a rare cause of PHPT associated with these tumors. Histopathological examination is necessary to confirm the diagnosis of APA and to differentiate it from PC, which has a recurrence rate &amp;gt;50%. APA should be treated as a “tumor of uncertain malignant potential” and needs to be carefully and periodically followed up with measurement of Ca, PTH and vitamin D. Confirmation of a CDC73 mutation by genetic testing helped identify the increased risk for other associated tumors in jaw, kidneys and uterus prompting initiation of surveillance with panoramic jaw x-rays with neck shielding, renal US and pelvis US. Genetic testing of family members will allow timely detection and treatment of individuals at risk. Presentation: 6/3/2024

7191 When Pain Is Misdiagnosed: A Case of Parathyroid Carcinoma Masked as Fibromyalgia

Abstract Disclosure: H. Pham: None. P.V. Kumar: None. S. Taylor: None. Parathyroid carcinoma is a rare and aggressive cause of hyperparathyroidism, typically associated with &amp;lt;1% of primary hyperparathyroidism cases. Incidence occurs mainly in the 5th decade of life, with less than 4% of all cases presenting in patients under age 30. Here, we highlight a case involving a 28-year-old woman with fibromyalgia who presented for worsening right shoulder pain in the setting of progressive, poorly characterized pain for the past year. Her initial physical exam was unremarkable aside from a non-tender left sided neck enlargement. However, her laboratory results were significant for corrected serum calcium of 15 mg/dL, serum phosphorus of 2.3 mg/dL, parathyroid hormone (PTH) &amp;gt;2500 pg/mL, and alkaline phosphatase 1604 units/L. X-ray of her right shoulder demonstrated mottled bone concerning for degenerative disease. Thyroid ultrasound revealed a complex cystic lesion posterior to the left thyroid lobe measuring 5.3 x 3.9 x 2.9 cm, worrisome for giant parathyroid adenoma. CT abdomen/pelvis showed diffuse osteosclerosis and innumerable lytic lesions, consistent with osteitis fibrosa cystica, as well as bilateral nephrolithiasis, likely medullary nephrocalcinosis. Her hypercalcemia was treated with aggressive hydration with normal saline and IV pamidronate. She underwent surgical resection of her parathyroid adenoma, which was unfortunately complicated by symptomatic hypocalcemia requiring prolonged care in the ICU. Her calcium levels did improve within a few days, and she was subsequently discharged with close outpatient follow-up. Final pathology report showed predominant thickened trabecular growth pattern with focal vascular invasion consistent with parathyroid carcinoma. Our patient’s case represents a rare presentation of parathyroid carcinoma in a young patient without any additional risk factors. Although atypical, her severe symptomatic hypercalcemia, nephrolithiasis, presence of large neck mass, and diffuse skeletal disease warranted immediate concern for malignant hyperparathyroidism instead of benign adenoma. Delayed diagnosis in our patient led to prolonged bone disease and severe complications. While hungry bone syndrome typically manifests post-parathyroidectomy in patients with end-stage renal disease, our patient experienced this complication in the setting of advanced, untreated hyperparathyroidism. We should consider hypercalcemia and hyperparathyroidism in our differential diagnosis for chronic pain, especially if pain remains uncontrolled with conservative measures. The most appropriate initial test for evaluation of hypercalcemia is a PTH level to distinguish between PTH-dependent and PTH-independent etiologies. Parathyroid carcinoma, even in young patients, should be considered when PTH is &amp;gt;3x upper limit of normal, serum calcium is &amp;gt;14, or skeletal and renal involvement is present. Presentation: 6/3/2024

7159 Brown Tumor As Primary Presentation Of Parathyroid Carcinoma In A Young Female

Abstract Disclosure: S.G. Zachariah: None. R. Anand: None. B.Y. Wong: None. H.J. Lee: None. Title Brown Tumor as Primary Presentation of Parathyroid Carcinoma in a Young Female Introduction/Background: Parathyroid carcinoma (PC) is a rare cause of hyperparathyroidism (HPT) accounting for less than 1% of primary HPT cases. The mean age of PC presentation is 62 years. Long-standing HPT can lead to the formation of osteitis fibrosis cystica (brown tumors). In today’s world of advanced screening, they are an increasingly rare presentation of HPT. We present a case of PC presenting as multiple brown tumors in a young woman. Case: A previously healthy 32-year-old woman presented to the emergency department with right shoulder pain after a mechanical fall. MRI revealed multiple osseous lesions of the proximal humerus, glenoid, and scapula, concerning for possible metastatic malignancy. Notable labs: calcium 13.6 mg/dL [8.5 - 10.5 mg/dL], phosphorus 1.7 mg/dL [2.5 - 4.5 mg/dL], alkaline phosphatase 2,369 U/L [&amp;lt; 130 U/L], 25-OH vitamin D 0.8 ng/mL [30 - 60 ng/mL], and parathyroid hormone greater than 2,500 pg/mL [20-80 pg/mL]. Albumin and renal function were normal. CT chest/abdomen/pelvis showed lytic lesions of the left 7th rib, anterior superior iliac spine (with nondisplaced fracture), pelvis, and sacrum. Subsequent pelvic biopsy showed fragmented bony trabeculae with osteoblastic rimming and rare osteoclasts, fragments of fibrous tissue with few plasma cells and hemosiderin laden macrophages, possibly consistent with brown tumor. On parathyroid ultrasound, a 2.2 cm cystic mass was seen along the left common carotid artery. CT neck confirmed the location and also reported C7-T1 spinal lesions. Calcium levels stabilized with IV fluids and 90 mg IV pamidronate. She underwent a left parathyroidectomy and left hemithyroidectomy with central neck dissection. Pathology was consistent with a low-grade parathyroid carcinoma, with a foci of angioinvasion and capsular invasion without lymph node metastases. The Ki-67 index was less than 1%. Post-operatively, the patient was started on calcium and calcitriol supplementation and did not experience hungry bone syndrome. On further discussion, the patient noted that she had a jaw tumor that was previously biopsied and found to be benign. The patient has since been referred for genetic testing. Conclusion/Clinical Lessons: Both PC and its initial presentation with brown tumors are uncommon. Even more rare is the presentation of both in a young, otherwise healthy female. In this context, it is also important to note that brown tumors can mimic osseous metastases and appropriate biochemical, imaging, and histopathological evaluation is needed. The diagnosis of PC under 40 years of age is uncommon and genetic testing is indicated. Syndromes including multiple endocrine neoplasia type 1, familial isolated hyperparathyroidism, and hyperparathyroidism-jaw tumor syndrome are potential causes of inherited PC. Presentation: 6/3/2024

7387 A Rare Case Of Concomitant Intrathyroidal Parathyroid Carcinoma With Osteitis Fibrosa Cystica, Masquerading As Oncocytic Thyroid Carcinoma - A Post-operative Diagnosis

Abstract Disclosure: Y. Koh: None. D.E. Chew: None. T.P. Quek: None. Introduction: Parathyroid carcinoma is a rare form of malignancy. An intrathyroidal location of parathyroid carcinoma further complicates the diagnosis as it may be mistakenly presumed to be of thyroid origin instead. We present a case report of an intrathyroidal parathyroid carcinoma which was diagnosed post-total thyroidectomy. Clinical case: A 72-year-old lady was found to have an intrathyroidal mass after presenting with unintentional weight loss and chronic constipation. Ultrasound of the neck showed a 4.0 x 2.9cm markedly hypoechoic solid mass in the mid-lower right thyroid lobe. Fine needle aspiration of the mass was suspicious for an oncocytic neoplasm. She underwent total thyroidectomy with central neck dissection for concerns of oncocytic thyroid carcinoma. Intraoperatively, a 4cm right hard intrathyroidal nodule invading into the right recurrent laryngeal nerve was observed. All 4 parathyroids were identified and preserved. Post-operatively, routine biochemistry to monitor for hypocalcemia showed hypercalcemia instead. This quickly transitioned into hypocalcemia on post-operative day 4, with biochemistry supportive of hungry bone syndrome [adjusted calcium 2.05mmol/L [normal range (NR) 2.15-2.5], phosphate 0.6mmol/L (NR 0.8-1.4), PTH 8.2pmol/L (NR 0.8-6.8), 25-OH vitamin D 18ug/L (NR 30-100)]. She was started on oral calcium carbonate, calcitriol and cholecalciferol aiming for normocalcemia. Evidence for underlying primary hyperparathyroidism were sought for, which showed osteitis fibrosa cystica, severe osteoporosis and an ossifying fibroma of the mandible, suggesting underlying hyperparathyroidism-jaw tumour-syndrome. The intra-operative histology was reported as oncocytic carcinoma with angio- and perineural invasion, presumed to be thyroid in origin. Given our suspicion of underlying primary hyperparathyroidism, we requested our pathology colleagues to perform additional immunochemical stains, which stained diffusely positive for parathyroid hormone, GATA3 but were negative for thyroglobulin, thyroid transcriptor factor-1, confirming its parathyroid origin. Her hungry bone syndrome resolved 22 weeks post-operatively. Till present (14 months post-operatively), her calcium and PTH levels remain normal and ultrasound of the neck did not reveal any evidence of recurrence. She declined genetic screening. Clinical Lesson: A high index of suspicion is required for the diagnosis of parathyroid carcinoma. In a patient who presents with constitutional symptoms and a neck mass, it is imperative to consider parathyroid disease as a differential diagnosis. A lesion with oncocytic morphology may be of parathyroid or thyroid origin, and the use of immunochemical stains can help differentiate them. Effective communication between clinicians and pathologists is essential in clinching the correct cytopathological diagnosis. Presentation: 6/3/2024

12313 Parathyroid Carcinoma Presenting As Right Foot Pain And Swelling In A Young Male - A Case Report

Abstract Disclosure: F.E. Sorsona: None. L. Lopez: None. Parathyroid carcinoma is a rare cause of hyperparathyroidism that is challenging to diagnose. We report a case of parathyroid carcinoma with an unusual initial presentation of right foot pain and swelling in a young 26-year-old Filipino male. Physical examination revealed a palpable 1 x 1 cm mass with tenderness on his right foot. Initial work-up showed a persistently elevated serum ionized calcium (range: 1.7 - 2.19 mmol/L) with markedly high intact parathyroid hormone (1,890 pg/ml). A right foot x-ray revealed a lytic bone lesion on the 3rd metatarsal. Skeletal survey revealed diffuse lytic bone lesions. Comprehensive neck ultrasound showed a 4 x 1.6 x 2.5 cm complex nodule adjacent to the inferior pole of the left lobe of the thyroid gland with intralesional calcifications. A 4D CT scan showed a 3.3 x 2.2 x 2 cm hypervascular nodule inferior to the left thyroid lobe with early contrast washout, likely parathyroid in origin, and a possible brown tumor in the right fourth rib. Patient underwent parathyroidectomy with intraoperative PTH monitoring showing a marked reduction of intact PTH by 87% (235.9 pg/ml from 1,890 pg/ml), accompanied by reduction of serum ionized calcium. The histopathology reported parathyroid carcinoma highlighted by lymphovascular invasion, atypical round cells in sheets and nests, with enlarged, mildly pleomorphic, hyperchromatic nuclei and prominent nucleoli. Two months after surgery, normal serum ionized calcium was maintained with calcium supplementation with reported relief of right foot pain and swelling. The patient continues to follow up regularly for monitoring of treatment response. Presentation: 6/2/2024

6699 Primary Hyperparathyroidism With Severe Hypercalcemia Secondary to Giant Parathyroid Adenoma

Abstract Disclosure: M.P. Lieberman-Ulm: None. M.A. Yanez-Bello: None. V.S. Lagari-Libhaber: None. Background: Parathyroid adenomas are often detected in asymptomatic patients without palpable neck mass and are responsible for 80 to 85% of cases of primary hyperparathyroidism. Oversized or “Giant” parathyroid adenomas (GPAs) are defined as parathyroid adenomas that weigh more than 3.5 g. These are rare, representing less than 1.5% of parathyroid adenomas. The majority of reported cases of GPAs are associated with elevation of PTH and calcium levels, though usually not as high as is seen in patients with parathyroid carcinoma, where PTH levels typically reach greater than three times the upper limit of normal and serum calcium greater than 14 mg/dL. Clinical Case: A 73-year-old man presented with altered mental status and was found to have severe hypercalcemia (serum calcium 20.5 mg/dL, albumin 4.4 g/dL) and AKI stage III (eGFR 16 mL/min/1.73m2). Physical exam showed palpable, mobile, left-sided fullness, and further lab evaluation revealed intact PTH of 2,934 pg/mL, vitamin D, 25-OH of 24.8 ng/mL, and PTHrP of 14 ng/mL. Phosphorous level was not collected prior to treatment. Neck ultrasound was unremarkable. CT revealed a 9 cm hypodense lesion inseparable from the posterior aspect of the left thyroid lobe extending inferiorly to the posterior mediastinum at the level of the carina. Sestamibi scan showed scintigraphic evidence of parathyroid adenoma in the left tracheoesophageal groove. Patient was treated with IV fluids, zoledronic acid, calcitonin, cinacalcet and furosemide in addition to receiving hemodialysis on arrival. He then underwent resection of the mediastinal parathyroid gland. Pathology revealed parathyroid adenoma (16.6 g) without evidence of gross or microscopic invasion into adjacent structures, vascular or perineural invasion. Size greater than 3.5 g classified this mass as a giant parathyroid adenoma. Post-operatively, the patient’s PTH and corrected calcium normalized (17 pg/mL and 9.4 mg/dL, respectively). Conclusion: Giant parathyroid adenomas are a rare cause of primary hyperparathyroidism. Generally, parathyroid adenomas present with less severe clinical and biochemical characteristics than those of parathyroid carcinomas. However, the characteristics of GPA can be similar to parathyroid carcinoma, and differentiating between the two can be challenging. Parathyroid masses are differentiated with histologic diagnosis along with haematoxylin and eosin stain findings. In the case of our patient, his clinical picture was suggestive of parathyroid carcinoma given the severity of his disease, but pathology revealed parathyroid adenoma. Additionally, his calcium and PTH levels normalized after parathyroidectomy. This case may be representative of rare, aggressive giant parathyroid adenoma, however close follow up is imperative to ensure patient does not develop metastatic disease in the future, which would suggest underlying malignancy all along. Presentation: 6/2/2024

8032 Clinical And Laboratory Characteristics Of Patients With Primary Hyperparathyroidism Followed At A Brazilian University Hospital

Abstract Disclosure: G. Koga: None. D. Amorim: None. L.M. dos Santos: None. D. Calixto: None. M. Ohe: None. J.G. Vieira: None. M. Lazaretti-Castro: None. Primary hyperparathyroidism (PHPT) is an endocrine disorder characterized by hypercalcemia due to hyperfunction of parathyroid glands. Its clinical presentation has been changing, becoming mostly asymptomatic. However, there are few data on developing countries.Objective: to describe clinical and biochemical features of primary hyperparathyroidism in a Brazilian population of a tertiary hospital. Methods: 259 individuals with PHPT are followed in a school-hospital in Sao Paulo in the last 2 years and this preliminary analysis included 161 of them. Clinical and laboratorial data were obtained by reviewing medical records. Data are presented as median [min-max] and statistical differences were considered if p&amp;lt;0.05. Results: 133 (82.6%) were women (3.7:1 female:male ratio) with a median age at diagnosis of 63 years [24-88]. There was higher prevalence of Caucasian (62.7%) then among Afro-descendants and Asians/indigenous: 35.4% and 1.9%, respectively. 99 (61.5%) patients were asymptomatic. Symptoms were observed in 38,5% (nephrolithiasis, fractures, bone pain, hypercalcemic crisis). Target organ involvement was evaluated: 48.4% had osteoporosis, and 47.2% kidney stones. At diagnosis, median total calcium (tCa) was 11.2 mg/dL [10.0-19.1], ionized calcium (iCa) 1.48 mmol/L [1.30-2.48], PTH 277.7 pg/mL [51.4-2374.0] and 25OHD 23.5 ng/mL [5.0-54.2]. Symptomatic patients were diagnosed younger (61 [24-83] vs 64 [31-88]; p=0.036), had higher tCa (11.4 [10.2-19.1] vs 11.2 [10-16]; p=0.049) and greater prevalence of 25OHD&amp;lt;20 ng/mL (50.0 vs 30.4%; p=0.03) than asymptomatic. Patients with severe hypercalcemia (&amp;gt;14 mg/dL) were diagnosed younger than those with non-severe hypercalcemia (52 [41-54] vs 63 [24-88] years; p=0.002). Patients with osteoporosis had older age at diagnosis compared to those without (64.0 [42-86] vs 61.5 [24-88]; p=0.018). Histological data were obtained from 94 individuals out of 104 submitted to surgery: 59.6% had single adenoma, 39.3% hyperplasia or multiple adenomas and 1.1% parathyroid carcinoma. Patients with single adenoma had higher levels of tCa and iCa than those with multiglandular disease (median of 11.4 [10.0-19.1] vs 10.9 [10.3-13.4]; p=0.042 and 1.52 [1.32-2.48] vs 1.43 [1.30-1.59]; p=0.02, respectively). Conclusion: Our preliminary data showed that most of the patients were Caucasian women presenting with asymptomatic disease. Compared with other countries, we still have a greater proportion of symptomatic presentations (38.5%) and multiglandular diseases (39.3%) than the reported in literature. Severe forms were diagnosed earlier, in younger patients and with a single adenoma, suggesting that they may have a different disease from the asymptomatic ones. These aspects demonstrate that there may be ethnic and environmental influences interfering with the presentation of this disease. Presentation: 6/2/2024

7090 The Largest Study on Asymptomatic Primary Hyperparathyroidism (APHPT) Conducted at the Tertiary Care Riga East Clinical University Hospital (RECUH)— Three Years of Data

Abstract Disclosure: D. Stūrīte: None. I. Rasa: None. Background: Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder and a leading cause of hypercalcemia in the outpatient setting. The study aimed to assess the characteristics, management and outcomes of pts with APHPT. Methods: A retrospective analysis of data from 168 pts with APHPT, evaluated at RECUH from January 2021 to November 2023 was conducted. Information obtained included medical records, laboratory data, imaging results, surgical protocols, histopathology data. Statistical analysis was performed using IBM SPSS 29.0. Results: From the 168 pts (mean age: 63.7±11.8 years), 86.3% (n=145) were females. Predominantly, 67.3% (n=113) exhibited mild hypercalcemia (2.6-3.0mmol/L), while 22.6% (n=38) had moderate hypercalcemia (3.0-3.49mmol/L), and 4.8% (n=8) -severe hypercalcemia (≥3.5mmol/L). 5.3% (n=9) had normocalcaemic PHPT. The mean preoperative maximal calcium level was 2.9±0.3mmol/L, iPTH level - 247.6±224.9pg/mL, minimal phosphorus - 1.3±6.7mmol/L and 25-OH vitamin D level - 28.3±14.7ng/mL. The mean preoperative eGFR was 90.6±28.2 ml/min/1.73m2, creatinine - 72.5±23.9μmol/L. Parathyroid adenoma sizes ranged from 0.3x0.4cm to 5.3x3.7cm. Calcium levels positively correlated with adenoma cross-sectional area (ρ=0.187, p=0.029) and maximal adenoma dimension (ρ=0.215, p=0.011). Ultrasonography convincingly detected parathyroid adenomas in 63.9% (107/168), SPECT/CT - 68.4% (52/76), 99mTc-sestamibi scintigraphy - 65.6% (61/93), 3D-CT - 70.6% (24/34), contrast-enhanced ultrasonography - 84% (21/25) and MRI in - 40% (2/5) cases. 12.5% (n=21) pts had unlocated parathyroid adenoma. 34.5% (n=58) of pts had osteoporosis, 47.6% (n=80) osteopenia, 12.5% (n=21) had a history of osteoporotic fracture, 17.3% (n=29) had gallstones and 22.0% (n=37) - kidney stones. 80.4% (n=135) of pts had thyroid nodules, 48.2% (n=81) - nontoxic goitre, 24.4% (n=31) - autoimmune thyroiditis, 41.7% (n=70) - hypertension, 10.5% (n=18) - type 2 diabetes. 18.5% (n=31) pts were found to have a diagnosis of malignancy. 61.9% (n=104) of pts underwent parathyroidectomy. Histopathology and radiologic imaging revealed single parathyroid adenoma in 95.2% (n=99), double parathyroid adenomas in 1.9% (n=2), parathyroid hyperplasia in 2.9% (n=3) and parathyroid carcinoma in 1.9% (n=2) pts. The mean maximal postoperative calcium level (n=103) was 2.4±0.1mmol/L, iPTH (n=101) - 63.5±27.7pg/mL, 25-OH vitamin D - 41.5±13.3ng/mL, and the mean minimal phosphorus (n=56) - 1.1±0.2mmol/L. Conclusions: APHPT remains frequently encountered and often showcases bone manifestations. It's crucial to consider the diverse clinical manifestations and associated conditions in patients with APHPT. Presentation: 6/2/2024