clinical reviews

Contemporary Evaluation and Management of

Parathyroid Carcinoma
Abbey L. Fingeret, MD1
abstract

Parathyroid carcinoma is a rare malignancy, representing 0.005% of all cancers and 0.5%-1% of all parathyroid
disorders. Parathyroid carcinoma occurs equally in males and females, as opposed to primary hyperpara-
thyroidism, which has a female predominance. Patients with parathyroid carcinoma present with symptoms of
hypercalcemia, similar to those with benign primary hyperparathyroidism. Parathyroid carcinoma should be
suspected when calcium or parathyroid hormone levels are high. Because of the difficulty of discerning
parathyroid carcinoma from adenoma preoperatively, the diagnosis of carcinoma is often made only after
parathyroidectomy. The goals of surgery are resection with negative margins because surgery represents the
only opportunity for cure. Adjuvant therapy with chemotherapy or external beam radiation has not been proven
to affect disease-free or overall survival for these patients. Recurrence is common, with reoperation recom-
mended for resectable recurrent disease. Palliation with calcimimetic pharmacotherapy can aid with man-
agement of symptomatic hypercalcemia in recurrent or persistent disease after parathyroidectomy. Ultimately,
patients succumb to sequelae of hypercalcemia rather than tumor burden.
JCO Oncol Pract 17:17-21. © 2020 by American Society of Clinical Oncology

INTRODUCTION after primary, secondary, or tertiary hyperparathyroid-

Author affiliations
and support
information (if
applicable) appear
at the end of this
article.
Accepted on
September 30, 2019
and published at
jop.ascopubs.org on
February 10, 2020:
DOI https://doi.org/10.
1200/JOP.19.00540
Parathyroid carcinoma is a rare malignancy repre-
senting less than 0.005% of all cancers and less than
1% of all parathyroid disorders.1-4 Although initially
described over 100 years ago in 1909 by de Quervain,
since that time, fewer than 1,000 patients have been
reported in the literature.5,6 Because of the rarity of this
malignancy, a standardized TNM staging algorithm
is not universally accepted. Primary index tumor size
and nodal involvement do not reliably correlate with
recurrence-free survival or overall survival.1 Therefore,
parathyroid carcinoma is described as localized, met-
astatic, or recurrent based on clinical and pathologic
findings rather than a standard four-stage system. The
10-year mortality rate for parathyroid carcinoma is
33.2%, with cancer-related mortality of 12.4%.1
The majority of patients with parathyroid carcinoma
have sporadic carcinoma, although a hereditary version
of the disease may be encountered associated with
hyperparathyroidism jaw-tumor syndrome (HPJT).7,8
Other genetic syndromes reported to be associated
with parathyroid carcinoma include multiple endocrine
neoplasia syndromes type 1 and type 2A, as well as
isolated familial hyperparathyroidism.7,9 Exclusive of
these genetic syndromes, no additional risk factors for
the development of parathyroid carcinoma have been
identified. Although the malignancy has been described
ism, no causal link of these benign disorders transforming
to malignancy has been identified.10-13 Parathyroid
carcinoma can be challenging to differentiate from
benign primary hyperparathyroidism (PHP) in the pre-
operative setting because of similarities in endocrine
hypersecretion and symptoms.5,10
CLINICAL PRESENTATION
The clinical presentation of most patients with
parathyroid carcinoma is similar to those with PHP.
With contemporary medicine in developed nations,
PHP is usually detected before the advent of symp-
toms or with only mild symptoms because of routine
biochemical screening, or it may present as neuro-
cognitive dysfunction with fatigue, depression, or im-
paired memory, focus, or attention; renal dysfunction
with nephrolithiasis, hypercalciuria, or decreased
glomerular filtration rate; skeletal dysfunction with
loss of bone mineral density or fragility fracture;
GI dysfunction with bloating, constipation, peptic ulcers,
or pancreatitis; or, rarely, cardiovascular disease.14
In contrast, patients with hormonally functional
parathyroid carcinoma often exhibit more severe
symptoms at the time of presentation and a multi-
plicity of system involvement due to more severe
hypercalcemia.4,15

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 Fingeret
Patients with nonsecreting parathyroid carcinoma are ex-
tremely challenging to diagnose and thus often present with
metastatic or disseminated disease. These nonfunctional
carcinomas account for less than 10% of all parathyroid
carcinomas. These patients may present with locally com-
pressive symptoms such as palpable neck mass or hoarse-
ness from recurrent laryngeal nerve invasion.16,17 Patients
who present with hoarseness should have a diagnostic
flexible laryngoscopy to assess their vocal cord function,
and ipsilateral vocal cord paralysis should increase the
index of suspicion for malignancy.18
Patients with parathyroid carcinoma have similar symptoms
to those with PHP, but may have differing clinical factors
(Table 1). In addition to more severely elevated parathyroid
hormone (PTH) and calcium levels, patients with para-
thyroid carcinoma tend to have more systems of in-
volvement in signs and symptoms, tend to be younger than
those with PHP at presentation, and are more likely to
present in hypercalcemic crisis than those with benign
disease.4,10 There are no specific tumor markers for
parathyroid carcinoma, although malignancy should be
suspected if serum calcium is . 14 mg/dL or the PTH level
is greater than three times the upper limit of normal.19
Finally, palpable neck mass is rare in benign parathyroid
disorders, but may be present in up to 70% of patients with
parathyroid carcinoma and should alert the clinician that
malignancy is more likely.5,9,20
Imaging to localize a parathyroid adenoma is standard in
the evaluation of PHP, and because parathyroid carcinoma
is most often diagnosed after parathyroidectomy, it is an
initial step in the work-up for the malignant entity as well.21
Initial imaging for PHP includes a neck ultrasound, followed
by 4-dimensional computed tomography or nuclear med-
icine radiolabeled technitium-99 sestamibi scans if non-
localized by ultrasound. These imaging modalities are
useful in tumor localization whether benign or malignant
but are not sufficiently sensitive or specific to assess
TABLE 1. Clinical Factors of Benign Primary Hyperparathyroidism and
Parathyroid Carcinoma
Benign Parathyroid
Factor Hyperparathyroidism Carcinoma
Sex distribution, 4:1 1:1
F:M frequency
Mean age at 55 48
presentation,
years
Serum calcium, , 13 . 14
mg/dL
Serum parathyroid . 1-3 3 above the $ 4 3 above the
hormone upper limit of upper limit of
normal normal
Palpable neck Rarely 70
mass, %
18 © 2020 by American Society of Clinical Oncology
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malignant potential. Retrospective review of preoperative
ultrasound identified that parathyroid carcinomas tended to
be larger, more heterogeneous, and more lobulated than
parathyroid adenomas.22,23 Lymph node metastases may
occur in 6%-30% of patients with parathyroid carcinoma at
presentation.1,15,24-26 The presence of lymphadenopathy on
preoperative imaging should alert the surgeon to have
a higher index of suspicion of parathyroid carcinoma. For
patients with a clinical suspicion of parathyroid carcinoma
preoperatively, cross-sectional imaging with computed
tomography or magnetic resonance imaging of the neck
may be useful to evaluate the extent and invasiveness of
local disease.
For patients with parathyroid carcinoma, 10%-30% will
have metastatic disease at presentation, most commonly to
the lung, bone, or liver.1,3,26 Additional imaging to evaluate
for metastatic disease is not routinely used for patients with
hyperparathyroidism, but should be considered for those
with a high index of suspicion for parathyroid carcinoma on
the basis of biochemical and clinical factors. The use of
[18F]fluorodeoxyglucose–positron emission tomography
(FDG-PET) has been studied in case series of parathyroid
carcinoma, although typically in the postoperative setting.
FDG-PET may help to identify parathyroid carcinoma recur-
rence or metastases when used 3-6 months postoperatively.27-29
Imaging for suspected recurrence of parathyroid carci-
noma should be considered for surveillance or when bio-
chemical recurrence with elevated PTH or hypercalcemia
occurs.
Fine-needle aspiration biopsy of suspected parathyroid
carcinoma is not recommended in the preoperative setting.
Cytology cannot reliably differentiate between parathyroid
adenoma and carcinoma.30 Furthermore, violation of the
capsule may cause tumor seeding in parathyroid carci-
noma, effectively upstaging the disease. Preoperative bi-
opsy may be considered when evaluating a patient with
a known diagnosis of parathyroid carcinoma to evaluate for
recurrent disease.25
TREATMENT
The mainstay of treatment of parathyroid carcinoma is
surgical resection. En bloc resection with negative margins
is the greatest strategy for cure. Effective operative man-
agement of parathyroid carcinoma is dependent on high
preoperative clinical suspicion or intraoperative identifi-
cation of malignancy on the basis of features of size,
capsular or local tissue invasion, and lymph node metas-
tases. Frozen section immediate-read pathology is not
helpful in distinguishing parathyroid adenoma from para-
thyroid carcinoma.
The goal of surgery is en bloc resection of all adjacent
tissues without capsular disruption to achieve grossly and
microscopically negative margins, including resection of
any adjacent fibroadipose or muscular soft tissue. Removal
Volume 17, Issue 1
 Parathyroid Carcinoma

of the ipsilateral thyroid lobe or uninvolved ipsilateral carcinomas, including cyclin D1, retinoblastoma, BRCA2,
parathyroid gland may be required to achieve this aim, p53, and the parathyroid adenomatosis gene-1.8,17,34-37
although this has not been shown to improve survival for
patients with parathyroid carcinoma.25,26 A regional lymph ADJUVANT THERAPY
node dissection of the central neck nodal compartment
Chemotherapy has not been shown to be effective in the
should be used for parathyroid carcinoma with suspected
treatment of parathyroid carcinoma.5,20,38,39 No clinical
nodal involvement.3,19 Frozen section immediate pathology
trials have been published to evaluate the utility of systemic
may be useful in the identification of parathyroid carcinoma
therapy, with most treatment regimens coming from an-
metastatic to regional lymph nodes but has an associated
ecdotal experience and case reports.40 Although suc-
false-negative rate and should not supersede clinical
cess has been reported with both monotherapy using
judgment. The recurrent laryngeal nerve can usually be
dacarbazine and combination therapy using fluoroura-
preserved to maintain vocal cord function but may require
cil, cyclophosphamide, and dacarbazine or methotrex-
resection if the tumor capsule abuts or invades. Intra-
ate, doxorubicin, cyclophosphamide, and lomustine, others
operative parathyroid hormone assay may be used, and if
have shown no response with combination therapy of
hormonally active disease has been adequately resected,
mithramycin, fluorouracil, and doxorubicin.20,40-42 The
will fall into the normal range. Persistent elevation of the
advent of novel therapeutic systemic therapy may improve
intraoperative PTH should not affect the decision for further
the response to pharmacotherapy in the future, although at
exploration at index operation if the local cervical disease
this time the decision to pursue adjuvant chemotherapy
has been eradicated because this may represent distant
should be individualized with appropriate counseling about
metastatic disease, and further exploration may increase
the lack of efficacy data.
the surgical morbidity.5
Similarly, there is no standard radiation therapy for para-
The pathologic findings of parathyroid carcinoma are pres-
thyroid carcinoma, which is generally thought to be radi-
ence of parenchymal mitoses, trabeculated parenchyma,
oinsensitive.32 Recently, several case series with a total of
including thick fibrous bands and capsular or vascular in-
16 patients treated with adjuvant radiotherapy have sug-
vasion.13 These features can also be seen in parathyroid
gested a possible benefit for local recurrence and disease-
adenoma with atypia, confounding an already challenging
free-survival.26,43,44 Decisions to treat with adjuvant radia-
diagnosis. Capsular or angiolymphatic invasion is the most
tion should be made on an individualized basis with a
specific indicator of carcinoma, and metastatic disease re-
multidisciplinary treatment team.
mains the only definitive indication of malignancy.7,31 It is not
surprising, therefore, that because of this challenging histo-
logic diagnosis, up to half of patients with metastatic para- PALLIATIVE THERAPY
thyroid carcinoma were initially diagnosed with benign Patients with parathyroid carcinoma may experience se-
parathyroid adenoma on pathology after parathyroidectomy.3 vere symptoms from hypercalcemia with unresectable pri-
A multidisciplinary approach is critical for the patient with mary disease or unresectable disease recurrence. Patients
suspected parathyroid carcinoma on the basis of preoperative with hypercalcemic crisis require hospital admission with
clinical factors, and the pathologist should be alerted to the intravenous hydration, loop diuretics, calcitonin, and in-
suspicion. If gland excision was the initial extent of surgery travenous bisphosphonate therapy for immediate control of
performed, local recurrence may be higher, at 51% electrolyte derangement. More commonly, however, pa-
compared with 8%, if en bloc resection was performed; therefore, tients require outpatient long-term medical management of
re-exploration with en bloc resection may be needed if chronic hypercalcemia. Calcimimetic therapy with cina-
histology results are malignant or concerning for atypia.32 calcet, a calcium-sensing receptor agonist, with or without
bisphosphonate therapy can decrease serum calcium
Genetic and molecular analysis may aid in the definitive
levels and associated symptoms.45 GI adverse effects are
diagnosis of parathyroid carcinoma. Although no single
common with calcimimetic therapy and include nausea,
molecular marker can distinguish between benign and
vomiting, diarrhea, and abdominal pain or bloating.46 Eth-
malignant parathyroid pathology, the most common
anol ablation may also be used for unresectable pri-
chromosomal aberrations in parathyroid carcinoma are the
mary or recurrent disease. Image-guided percutaneous
loss of 1p and 13q with gains in 19p, Xc-q13, 9p33qter, 1q,
injection of 98% ethanol into metastatic tumor deposits
and 16p.33 Parafibromin (HPRT2) is a nuclear protein that
under ultrasound guidance has been demonstrated to
regulates transcription and is mutated in HPJT, a disorder
decrease serum PTH levels and improve refractory
in which up to 15% of patients develop parathyroid car-
hypercalcemia.47
cinoma. HPRT2 may be mutated in up to three quarters
of patients with sporadic parathyroid carcinoma.8 Tradi-
tional cell-cycle regulators may also play a role in the PROGNOSIS
pathogenesis of parathyroid carcinoma, with abnormal The prognosis for parathyroid carcinoma is dependent on
expression of these regulators noted in many parathyroid the completeness of resection at initial diagnosis and

JCO Oncology Practice 19

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 Fingeret

operation because of the limited adjuvant treatment op-
tions. Staging is challenging because of the incongruence
among tumor size, nodal metastases, and disease-free or
overall survival. Survival rates for patients with complete en
bloc resection with negative margins are up to 90% at
5 years and 67% at 10 years.48 Ultimately, many patients
have disease recurrence after resection, with reported rates
of 50%-100%.19,46,49,50 The mean time to recurrence
ranges from 2 to 23 years after resection, with most re-
currence occurring in the regional operative field.15,25,34
Local recurrence with reoperation increases operative
risk sequentially, particularly permanent voice change from
recurrent laryngeal nerve involvement or injury, although
the mainstay of therapy is resection of amenable recurrent
disease. Distant metastases may occur via hematogenous
spread in 25% of patients, with lung, bone, and liver being
the most common sites.3 Ultimately, patients experience
morbidity and mortality from the sequelae of hypercalcemia
and concomitant associated end organ damage.
SUMMARY
Parathyroid carcinoma is a rare endocrine malignancy.
Preoperative diagnosis is challenging and requires a high
index of suspicion, with extremely elevated calcium or
PTH levels, palpable neck mass, hoarseness, or evi-
dence of lymphadenopathy on preoperative imaging.
The mainstay of treatment with curative intent is en bloc
resection with grossly and microscopically negative
margins. Chemotherapy and radiation therapy have
a limited role in the adjuvant management of parathyroid
carcinoma. Calcimimetic and bisphosphonate therapy
may palliate symptoms of recurrence with intractable
hypercalcemia.

AFFILIATION AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF

1
University of Nebraska Medical Center, Omaha, NE INTEREST
Disclosures provided by the author are available with this article at DOI
CORRESPONDING AUTHOR https://doi.org/10.1200/JOP.19.00540.
Abbey L. Fingeret, MD, 986880 Nebraska Medical Center, Omaha, NE
68198-6880; e-mail: abbey.fingeret@unmc.edu.

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n n n

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 Fingeret

AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Contemporary Evaluation and Management of Parathyroid Carcinoma
The following represents disclosure information provided by the author of this manuscript. All relationships are considered compensated unless otherwise noted.
Relationships are self-held unless noted. I 5 Immediate Family Member, Inst 5 My Institution. Relationships may not relate to the subject matter of this manuscript.
For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/site/ifc/journal-policies.html.
Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Abbey L. Fingeret
No potential conflicts of interest were reported.

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