Pune, 23rd January 2024: Recently, a 62-year-old male with parathyroid gland cancer was successfully treated at Manipal Hospital, Pune. The patient came to the hospital with a complaint of prolonged weakness, pain in the bones, and abnormal parameters from his kidney function test. Upon further investigation, Dr. Vikrant Gosavi, Consultant Endocrinologist, found that he had a history of kidney problems for the past 2 years, which was managed with medications and all biochemical tests suggested the diagnosis of ‘primary hyperparathyroidism’. A nuclear scan done showed two tumors on either side of the thyroid gland. Determining which tumor was the culprit and which one was an incidental bystander was a challenge; hence, a decision was made to perform a specialized test called ‘needle PTH’ level, performed by Dr Santosh Patil [Interventional Radiologist], which revealed that the tumor on the right side was the source of the disease.
Furthermore, the tumor was suspected to be malignant by the treating Endocrinologist based on the images from his CT scan and the same was communicated to the surgeon and a decision was made to operate him based on oncological principles with high suspicion. Dr. Rahul Wagh, Consultant Surgical Oncologist, Manipal Hospital, Baner, counseled the patient’s family and performed surgery to remove the tumour on the right side while leaving the left side un-operated. During surgery, it was found that the parathyroid lesion was densely adherent to the right-side thyroid lobe. Keeping in mind the possibility of cancer, the tumour was removed along with the right thyroid lobe without any spillage. Hormone levels dropped drastically immediately after the surgery, and later it was confirmed that the tumour was in fact cancer.
Since there was a pre-emptive suspicion of cancer, the surgery was done according to oncological principles & the patient was cured in the first surgery itself, obviating the need for reoperation and associated complications, as well as the unnecessary surgery on the left side of the neck. Furthermore, he did not need any other adjuvant treatments like radiation, as an oncosurgeon had operated on him with the suspicion of malignancy in mind.
Parathyroid hormone is made by four grain-sized parathyroid glands situated around the thyroid gland in our neck. Primary hyperparathyroidism occurs when a tumour arises in one of these glands, causing excessive, uncontrolled production of PTH, which raises the blood calcium level while weakening bones and damaging the kidneys. Primary hyperparathyroidism is the third most common endocrine disorder (after diabetes and thyroid disorders), and unfortunately, it usually remains undiagnosed for up to 5 years despite symptom onset. Parathyroid carcinomas are a very rare and aggressive type of malignancy. Although most parathyroid tumours are benign, there is a <1% chance of them being cancerous. The annual incidence of parathyroid carcinoma is 3 to 5 cases per 10,000,000 population.
Commenting on the challenges of this case, Dr. Vikrant Gosavi, Consultant, Endocrinology, Manipal Hospital, Baner-Pune, said, “Localizing the tumour was very important but tricky because the nuclear scan was showing equal possibility of disease on both sides of thyroid and we did not want to subject the patient to an extensive surgery which may leave him morbid throughout his life. We were able to suspect the cancerous nature of this tumor based on scan images before surgery itself and saved him from a second revision surgery ahead.”
Dr. Rahul Wagh, Consultant Surgical Oncology, Manipal Hospital, Baner-Pune, said, “The possibility of malignancy (1% chance) required extra caution in the pre-operative setup, mirroring protocols for treating malignant cancers. During surgery, the tumour’s tight adherence to the thyroid gland added complexity, requiring careful removal while avoiding spillage. The tumour was removed successfully, and the dizziness and bone pain subsided post-surgery. The patient is now doing well and is on regular follow-ups.”