Aim: The description of a rare case of diffuse lung metastases from a cancer of the parathyroid gland in a woman with a history of ovarian carcinoma.
Case report: Female, 77 years-old, with a negative family history for malignancy and a personal history of an operated ovarian cancer, which presented 3 years ago (mucinous adenocarcinoma, st IIc), for which the patient received 5 cycles of chemotherapy (carboplatin) and was then followed-up (CA-125 every 6 months and CT of the abdomen every year), on the 06/2008 presented with a small amount of ascitis and pleural effusion, as was shown in the CT of the abdomen. The patient was admitted in our department with the suspicion of relapse of the ovarian cancer. The tumor marker CA-125, in consequent measurements, was normal. The chest X-ray revealed multiple nodules in both lungs and pleural effusion. A high resolution CT ofthe thorax was then performed, which showed miliary nodules in both lungs, right pleural effusion, but no pathologically enlarged lymph nodes. The biochemical work-up showed hypercalcemia (13,4 mg/dl) and low phosphorus (2,4 mg/ dl). From the previous medical history ofthe patient, there was a known primary hyperparathyroidism, diagnosed 2 years before (PTH 285pg/ml, Ca 11,6 mg/dl). A U/S of the thyroid was performed the previous year which revealed a solid nodule in the left lobe ofthe gland, with cystic degeneration in the circumference. In the scanning ofthe thyroid with Tc-99, the nodule had very little intake of the radionuclide (cold area), while the scanning of the parathyroid glands with sestamibi-Tc99 had revealed persistent intake of the radionuclide in the left lobe ofthe gland. The diagnosis was adenoma of the parathyroid gland, but the patient refused to undergo a surgical excision. During her present admition, the patient was submitted to a scanning of the parathyroid with sestamibi-Tc99, which except from the known area of intake ofthe radionuclide in the left lobe of the thyroid, also revealed diffuse persistent intake in both lungs. The cytologic examination of the pleural fluid and the bronchioalveolar lavage (BAL) showed adenocarcinoma. The MRI of the neck revealed a solid mass in the anatomic area of the left lower parathyroid gland. The FNA of the mass revealed the presence of parathyroid gland cells with atypical abnormalities which were insufficient to confirm the malignancy. The immunohistochemistry showed PTH positivity. The rest of the workup: PTH 250pg/ml, Ca 13,5mg/dl, P 2,4mg/dl and Vitamin 1,25-0H D3, Ca and P of the urine (after a 24 hour collection), hormonal examination of the thyroid and renal function were in normal range. The X-rays of the ischium and the hands showed intense osteopenia and osteoporosis of the bones of the wrist, of the metacarpal and of the phalanxes.
Conclusion: Multiple lung metastases from cancer of the parathyroid glands in a woman with a history of mucinous cystadenocarcinoma of the ovary is a rare entity. PTH, Ca, scanning of the parathyroids with sestamibi-Tc99 and immunohistochemical analysis are examinations that may contribute to the diagnosis.