Parathyroid Carcinoma in a Chronic Hemodialysis Patient

G. Gopal Krishna, MD, Section of Nephrology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140 (USA) Dear Sir, Hyperparathyroidism and parathyroid hyperplasia invariably accompany chronic renal failure [1]. However, parathyroid carcinoma rarely occurs in this setting. Indeed, our survey of the English language literature revealed only one patient developing this lesion during chronic renal failure [2]. We report a second patient manifesting such an association. A 64-year-old white female developed end-stage renal disease in 1976 secondary to idiopathic chronic interstitial nephritis. Her serum calcium at that time was 9 mg/dl (1.97 mmol/l), phosphorus 7.9 mg/dl (2.55 mmol/l) with a normal albumin concentration. Despite therapy with phosphate-binding agents, serum phosphate levels remained greater than 6 mg/dl (1.94 mmol/l). Over the next several years she developed multiple bone fractures (ribs, ankle and hip) from severe secondary hyperparathyroidism. Beginning in September 1983, serum calcium levels ranged from 10 to 11 mg/dl (2.50–2.74 mmol/l). Parathyroid hormone (PTH) levels (C-terminal assay) in February 1985 were greater than 10,000 pg/ml (normal 0–340 pg/ml). At parathyroidectomy in May 1985, the two inferior glands were hyperplastic while both superior glands revealed malignant changes with infiltration of adjacent thyroid tissue (fig. 1). Immunoperoxidase studies using monoclonal antibodies, positive for PTH and negative for thyroglobulin, confirmed that the tumor indeed originated from parathyroid tissue. No metastatic foci were identified in the seven paratracheal lymph nodes resected. As of June 1988 the patient is in a stable condition with no clinical evidence of metastatic disease. Parathyroid carcinoma is a rare cause of hyperparathyroidism, accounting for only 1–3% of patients with