Control of hypercalcaemia of parathyroid carcinoma by immunisation

Multiple Metastases of Parathyroid and Papillary Thyroid Carcinoma in a Female Patient Treated with Long-Term Hemodialysis

Parathyroid cancer is a rare, clinically aggressive malignancy with a prevalence of approximately 0.005% relative to all carcinoma cases and 1-5% among patients with primary hyperparathyroidism. Prognosis largely depends on the extent of the primary surgery. Non-radical surgical treatment increases the risk of local and distant metastases of the parathyroid cancer associated with limited treatment options. The combination of thyroid and parathyroid disorders has been described rather well for the general population; however, cases of parathyroid and thyroid carcinoma in the same patient are extremely rare (1 case per 3000 patients with parathyroid disorders). We present a rare clinical case of combination of parathyroid and thyroid cancers with metastases of both tumors to the neck lymph nodes in a woman with a mutation in the MEN1 gene (NM_130799.2): c.658T > C p.Trp220Arg (W220R), who has been exposed to radiation for 20 years before diagnosis of thyroid cancer and received renal replacement therapy with long-term hemodialysis before the diagnosis of parathyroid cancer. The patient underwent several surgeries because of metastases of the parathyroid cancer in the neck lymph nodes. Surgeons used intraoperative navigation methods (single-channel gamma detection probe, Gamma Probe 2, and fluorescence angiography with indocyanine green (ICG)) to clarify the volume of surgery. Currently, the patient is still in laboratory remission, despite the structural recurrence of tumors.

Treatment and outcome of metastatic parathyroid carcinoma: A systematic review and pooled analysis of published cases

Background

Parathyroid carcinoma (PC) is an extremely rare malignant tumor with an incidence of about 6 new cases per 10 million inhabitants per year. While several papers have been published on treatments and outcomes of PC patients with loco-regional disease, little is known about the prognosis, treatment strategies, and prognostic factors of patients with distant metastasis.

Materials and methods

We performed a systematic review and a pooled analysis of histopathologically confirmed PC cases published in literature using the following keywords: “metastasis–metastatic–secondary nodes” AND “parathyroid carcinoma”. Original case reports and case series reporting metastatic parathyroid carcinoma were included. Data from 58 articles were extracted in a piloted form by five reviewers on a shared database.

Results

Seventy-nine patients with metastatic PC were identified between 1898 and 2018. Ten (13%) patients had synchronous metastases, while metachronous metastases occurred in 43 (54%) patients. The remaining 26 patients developed metastatic disease concomitantly to local recurrence. Primary hyperparathyroidism guided the diagnosis of metastatic recurrence in 58 (73%) patients. Surgery was the main primary approach adopted, as it was performed in 43 (54%) patients. Twenty (25%) patients underwent systemic antineoplastic therapy, consisting of chemotherapy, immunotherapy, tyrosine kinase inhibitors, and hexestrol therapy. Bone resorption inhibitors had a limited efficacy in the long-term control of hypercalcemia. After a median follow-up of 37.5 months, 43 (55%) patients died, 22 (51%) due to the consequences of uncontrolled PHPT. The median overall survival was 36 months (range: 1–252). Surgery was associated with a better OS (HR 0.48, 95% CI 0.26–0.88), whereas bone metastases represented a negative prognostic factor (HR 2.7, 95% CI 1.4–5.2).

Conclusion

Metastatic PC has a relatively poor prognosis. The main goals of treatment are to counteract tumor growth and control hypercalcemia. Surgery of metastases is the best approach to achieve rapid control of PHPT and longer survival. Target therapies and immunotherapy deserve to be extensively tested in metastatic PC and strategies to better control hypercalcemia should be implemented.

Mortality factors in recurrent parathyroid cancer: a pooled analysis

INTRODUCTION

Parathyroid cancer is a rare disease with high recurrence rate. The prognostic factors for recurrent parathyroid cancer are yet to be ascertained. We aimed to establish the association between recurrent parathyroid cancer and previously reported prognostic factors.

MATERIALS AND METHODS

We conducted a PubMed search using the keywords 'parathyroid cancer', 'parathyroid neoplasm', and 'hypercalcemia' during 1966-2019 and included 3272 articles. We focused on 73 patients with recurrent parathyroid cancer from 55 studies. We conducted a survival analysis using the Cox proportional hazards model with 95% confidence interval.

RESULTS

For the 73 patients included in the analysis, the mean age (± standard deviation) was 44 ± 13.2 years, wherein 36 patients were women (49.3%). During the 5236 person-months at risk (mean follow-up 71.7 months, range 3-264), 38 patients died. The incidence of local recurrence, lymph-node metastasis, lung metastasis, and bone metastasis were 60.3, 12.3, 56.2, and 24.7, respectively. Bone metastasis, disease-free interval < 1 year, and total surgeries < 3 were significant prognostic factors in univariate analysis (log-rank test P = 0.0063, P = 0.0006, and P = 0.0056, respectively). In the multivariate-adjusted analysis, the mortality risk was significantly increased in patients with bone metastasis with a hazard ratio (HR) of 4.83 (95% CI 1.16-20.2; P = 0.03), disease-free interval <=1 year of 5.92 (95% CI 1.85-18.99; P = 0.003), and total surgeries <3 of 11.29 (95% CI 2.82-45.22; P = 0.001), considering these as possible predictive prognostic factors.

CONCLUSION

Bone metastasis, duration of disease-free interval, and total number of surgeries predict survival in recurrent parathyroid cancer.

Metastatic parathyroid cancer: a rare cause of hypercalcaemia

A 45-year-old man presenting with abdominal pain was found to have severe hypercalcaemia with elevated parathyroid hormone. Investigations revealed a parathyroid mass and bone metastases consistent with metastatic parathyroid carcinoma. The patient underwent parathyroidectomy, with histology confirming a right inferior parathyroid carcinoma. His postoperative management was complicated by severe hypercalcaemia refractory to medical therapy, owing to the metastases continuing to produce parathyroid hormone. Despite palliative radiotherapy to the metastases, the patient died within 3 months from end-organ failure related to hypercalcaemia.

Management and Outcome of Parathyroid Carcinoma-Induced Primary Hyperparathyroidism: A Single-Centre Experience

BACKGROUND

Parathyroid carcinoma (PC) is the rarest endocrine cancer and an infrequent cause of primary hyperparathyroidism (PHPT), responsible for less than 1% of cases. Due to its rarity, treatment is challenging.

METHODS

A retrospective cohort study on 462 patients referred for parathyroidectomy to Thyroid and Parathyroid Unit at Santi Paolo e Carlo Hospital, Milan, Italy, from 2011 to 2021. We identified and individually described the patients affected with PC. Then, we split all patients treated for PHPT into four groups based on the cause: PC, adenoma, atypical adenoma, and hyperplasia. Patients' demographics, preoperative evaluation results, intraoperative findings, and outcomes for the PC group were compared with groups of PHPT due to benign causes.

RESULTS

Eight cases of PC were identified, five males and three females. Seven cases presented with symptoms of hypercalcemia and one with a neck mass. Five underwent en bloc resections and three local excisions. Histopathological features showed capsular invasion in four patients, capsular and soft tissue invasion in three patients, and vascular invasion in one case. No patients had distant metastasis. One patient was classed as high risk based on the Schulte classification system. All patients treated for PC were alive and disease-free at a mean follow-up of 38.4 months. When compared with other PHPT patients, PC patients were more frequently male and had higher preoperative blood calcium and PTH and lower phosphate levels, larger and heavier parathyroids excised, lower postoperative calcium, and a higher rate of postoperative hypoparathyroidism.

CONCLUSION

Our study highlights some aspects valuable to suspect PC and differentiate PHPT-PC from benign causes of PHPT preoperatively. Preoperative suspicion of malignancy is essential to guarantee the best course of treatment for patients. Although limited for size and follow-up, the excellent outcome of our series seems to support the value of both surgery extension and risk class according to the Schulte classification as possible prognostic factors for recurrence.

Long-term remission of disseminated parathyroid cancer following immunotherapy

PURPOSE

Parathyroid cancer is a rare tumor associated with poor prognosis particularly when disseminated. While chemotherapy and/or radiotherapy are of no clinical value in disseminated disease, immunotherapy should be considered.

SUBJECT AND RESULTS

A patient with CDC73-associated metastatic parathyroid carcinoma was treated with combined anti-hPTH immunotherapy and surgery.

CONCLUSIONS

Following five courses of anti-hPTH immunotherapy and subsequent surgery, a 12-year long remission of disseminated parathyroid cancer is reported. This case further supports the ever-expanding spectrum of cancers that may benefit from immunotherapy.

MGMT Promoter Methylation and Parathyroid Carcinoma

Context

Parathyroid carcinoma (PC) is extremely rare. Prognosis is poor, with no known evidence-based systemic therapies. We previously reported complete remission in a patient with metastasized parathyroid carcinoma and high tumor MGMT promoter methylation status who was treated with temozolomide.

Objective

To study MGMT promoter methylation status in an additional set of aggressive parathyroid tumors.

Design/Setting

The study included 12 patients: 7 with sporadic and 5 with familial primary hyperparathyroidism (two of the latter carried a CDC73 gross deletion). Patient 9 is the previously described patient with PC and high MGMT methylation status. Her daughter (patient 12) had surgery for severe primary hyperparathyroidism due to atypical parathyroid adenoma during pregnancy. Eleven patients thus had PC and one had atypical parathyroid adenoma. MGMT promoter methylation status was determined from DNA extracted from primary (n = 10) or metastatic (n = 2) tumors. A mean methylation level >20% was considered high. Patient 11 had metastatic PC and received temozolomide cycles.

Results

Only the previously published patient (patient 9) had high tumor MGMT promoter methylation status. This was not a characteristic of the atypical parathyroid adenoma of the daughter (patient 12). Patient 11 (CDC73 intragenic deletion) has disseminated PC, low MGMT promoter methylation, and stable disease on follow-up after temozolomide treatment.

Conclusion

High MGMT promoter methylation status seems rare in PC. However, as demonstrated in other neuroendocrine tumors, some patients with disseminated PC might benefit from temozolomide. Demonstration of high methylation status could be a predictor of positive response to temozolomide treatment.

MANAGEMENT OF ENDOCRINE DISEASE: Unmet therapeutic, educational and scientific needs in parathyroid disorders

PARAT, a new European Society of Endocrinology program, aims to identify unmet scientific and educational needs of parathyroid disorders, such as primary hyperparathyroidism (PHPT), including parathyroid cancer (PC), and hypoparathyroidism (HypoPT). The discussions and consensus statements from the first PARAT workshop (September 2018) are reviewed. PHPT has a high prevalence in Western communities, PHPT has a high prevalence in Western communities, yet evidence is sparse concerning the natural history and whether morbidity and long-term outcomes are related to hypercalcemia or plasma PTH concentrations, or both. Cardiovascular mortality and prevalence of low energy fractures are increased, whereas Quality of Life is decreased, although their reversibility by treatment of PHPT has not been convincingly demonstrated. PC is a rare cause of PHPT, with an increasing incidence, and international collaborative studies are required to advance knowledge of the genetic mechanisms, biomarkers for disease activity, and optimal treatments. For example, ~20% of PCs demonstrate high mutational burden, and identifying targetable DNA variations, gene amplifications and gene fusions may facilitate personalized care, such as different forms of immunotherapy or targeted therapy. HypoPT, a designated orphan disease, is associated with a high risk of symptoms and complications. Most cases are secondary to neck surgery. However, there is a need to better understand the relation between disease biomarkers and intellectual function, and to establish the role of PTH in target tissues, as these may facilitate the appropriate use of PTH substitution therapy. Management of parathyroid disorders is challenging, and PARAT has highlighted the need for international transdisciplinary scientific and educational studies in advancing in this field.

Current concepts in parathyroid carcinoma: a single Centre experience

BACKGROUND

Parathyroid carcinoma is a rare neoplasm that may present sporadically or in the context of a genetic syndrome. Diagnosis and management are challenging due to the lack of clinical and pathological features that may reliably distinguish malignant from benign disease.

METHODS

From January 2013 to December 2017, from 358 consecutive patients affected by parathyroid diseases, 3 patients with parathyroid carcinoma were treated at our academic Department of General Surgery. We present our experience as illustrative of the different features of clinical presentation of parathyroid carcinoma and review its management considering the recent relevant literature.

RESULTS

Case 1: A 62-year-old man was hospitalized for left-sided palpable neck mass, hypercalcemia and elevated PTH. US-guided FNA was suspect for parathyroid carcinoma. A large cystic mass was excised in bloc with total thyroidectomy and central neck dissection. Genetic studies framed a pathologically confirmed parathyroid carcinoma within MEN1 syndrome. Case 2: A 48-year-old woman with hypothyroidism had total thyroidectomy performed for a suspect for right follicular thyroid lesion. Pathology revealed parathyroid carcinoma. Case 3: A 47 year-old man was admitted for hypercalcaemic crisis and renal failure in the context of PHPT. A lesion suggestive on US and MIBI scan for parathyroid adenoma in the right lower position was removed by mini-invasive approach. Pathology revealed parathyroid cancer and patient had completion hemythyroidectomy and central neck dissection.

CONCLUSION

Parathyroid cancer is a particularly rare endocrine malignancy, however it should be suspected in patients with primary hyperparathyroidism when severe hypercalcemia is associated to cervical mass, renal and skeletal disease. Parathyroid surgery remains the mainstay of treatment. Radical tumour resection and expedited treatment in a dedicated endocrine Center represent crucial prognostic factors.

Parathyroid carcinoma

Parathyroid carcinoma (PC) is a rare disease with an indolent behavior due to the low malignant potential. The etiology is unknown. Somatic mutations of CDC73 gene, the same gene involved in the hyperparathyroidism-jaw tumor syndrome, can be identified in up to 70% of patients with PC and in one-third of cases the mutations are germline. Therefore, in patients who carry germline CDC73 gene mutations, its finding permits to identify the carriers among relatives and sometimes to early detect a parathyroid lesion in such subjects. The diagnosis of PC is commonly made after surgery, however there are some clinical/biochemical features that should raise the suspicion of PC, namely markedly elevated serum calcium and PTH levels, a large parathyroid lesion with suspected ultrasonographic features of malignancy, the damages of kidney and bones. The best chance of cure is the complete surgical resection with the en-bloc excision at the first operation, however several recurrences are often observed during the follow-up. Since PC is an indolent tumor with long-lasting survival and the death is due to complications of untreatable hypercalcemia, multiple surgical interventions with debulking of tumoral tissues along with medical treatment for reducing hypercalcemia are often needed. Patients with PC should be followed up along their lifetime.

Clinical characteristics and treatment outcomes of parathyroid carcinoma: A retrospective review of 234 cases

Parathyroid carcinoma (PC) is one of the rarest known types of cancer and has a moderate prognosis, with estimated 5- and 10-year overall survival rates between 78–85% and between 49–70%, respectively. To raise awareness of this disease, and to optimize its diagnosis, clinical management and prognosis, the present study retrospectively reviewed 234 cases of PC. A total of 226 cases of PC, which were archived between 1984 and 2015 in the three major databases of the Chinese population, were retrieved and pooled with the 8 cases diagnosed and treated at the Department of Thyroid Surgery of The First Hospital of Jilin University (Changchun, China) between June 2008 and December 2015. The clinicopathological features, diagnosis, surgical procedures and outcomes of these cases of PC were investigated. The review revealed that misdiagnosis has been a considerable issue, with >80% of the patients misdiagnosed prior to surgery, and the accuracy of intraoperative diagnosis based on frozen sections was only 15.04%. The use of radical resection as first-line therapy significantly improved the disease-free survival by ~8 years (log-rank, 20.956; P<0.001); and, at relapse, reoperation prolonged patient survival by ~7 years (log-rank, 35.322; P<0.001). Consistently, a Cox proportional hazards analysis indicated that radical resection as a first-line therapy reduced the risk of postoperative recurrence (P=0.030), and that reoperation following recurrence significantly improved patient survival (P=0.030). The 5- and 10-year cumulative disease-specific survival rates of the cases of PC were 83 and 67%, respectively. Notably, an increased mortality rate was observed among males with PC compared with female patients with PC. In summary, in the past 32 years (1984–2015), the majority of patients with PC have been misdiagnosed. Performing radical resection as the first-line therapy significantly reduces recurrence and improves patient survival time; and, following relapse, subsequent surgery has also been demonstrated to be an effective approach.

Parathyroid cancer

Parathyroid carcinoma is an exceedingly rare endocrine malignancy first described in 1933. It accounts for between 0.5% and 5% of all cases of primary hyperparathyroidism. Parathyroid carcinoma is unusual among endocrine malignancies, being more hormonally active than its benign counterpart. Parathyroid carcinoma poses a diagnostic challenge both clinically and histologically due to the lack of features which can definitively distinguish malignant from benign disease early in its clinical course. Here, we describe the clinical features of the disease, and present the current opinion on optimal management. Further, we analyse the most recent histological advances made to aid in the diagnosis and management of this rare, but potentially devastating, disease.

Parathyroid cancer and the CDC73 tumor suppressor gene

Parathyroid carcinoma (PC) is a rare endocrine neoplasm, usually causing severe primary hyperparathyroidism, that frequently causes death from unmanageable hypercalcemia. PC is frequently associated with somatic inactivating mutations of the CDC73 gene (previously called HRPT2), a gene discovered in association with the familial hyperparathyroidism-jaw tumor syndrome. DNA analysis for CDC73 mutation should be performed on all patients with seemingly sporadic PC since some 25% will carry a germline mutation. It is often difficult to make a firm diagnosis of PC by histopathology alone. That diagnosis often depends on the presence of local tissue invasion or distant metastases. If PC is suspected, en bloc resection at initial surgery is recommended. Medical therapy with cinacalcet, bisphosphonates or denosumab may temporarily ameliorate the hypercalcemia of inoperable PC.

Refractory hypercalcaemia secondary to parathyroid carcinoma: response to high-dose denosumab

OBJECTIVE

Hypercalcaemia is an important cause of increased morbidity and mortality in patients with parathyroid carcinoma. Surgical resection is the mainstay of treatment but, equally, managing hypercalcaemia is of paramount importance. At present, few therapies have been shown to be effective in the most severe cases. This report describes the efficacy of denosumab in a patient with parathyroid carcinoma when conventional therapies had been shown to be relatively ineffective.SUBJECT, METHODS AND RESULTS: A 50-year-old man presented with symptomatic hypercalcaemia 1 year after the surgery for his parathyroid carcinoma. Investigations revealed raised serum calcium and parathyroid hormone concentrations consistent with the recurrence of the disease. Imaging failed to localise any surgically remediable foci. Medical management with loop diuretics, calcimimetics and bisphosphonates failed to provide a sustained response. Denosumab, as a monthly injection, led to a gradual decrement in his peak calcium concentrations with the values now persistently below 3 mmol/l.

CONCLUSIONS

Denosumab, a fully human MAB that binds to the 'receptor activator of nuclear factor κB ligand (RANKL)', was shown to have a profound effect in modulating malignant hypercalcaemia. This medication should be considered as an effective option in patients with refractory hypercalcaemia secondary to parathyroid carcinoma.

Inoculation of dogs with a recombinant ACTH vaccine

OBJECTIVE

To determine whether inoculation of healthy dogs with a recombinant peptide containing 3 copies of ACTH would result in the production of antibodies against ACTH and whether this would affect pituitary-adrenocortical function.

ANIMALS

8 healthy dogs.

PROCEDURES

A recombinant peptide consisting of 3 copies of ACTH fused to a T-helper cell epitope was produced in Escherichia coli. The protein was inoculated into 4 dogs at 4-week intervals (total of 3 inoculations/dog). Four control dogs received inoculations of PBS solution mixed with adjuvant. Blood samples were collected for determination of antibody titers against ACTH and for measurement of basal and ACTH-stimulated plasma cortisol concentrations.

RESULTS

Inoculation with the ACTH vaccine resulted in production of anti-ACTH antibodies in all 4 dogs. Titers were initially high but declined by 15 weeks after the initial inoculation. Basal cortisol concentrations were unaffected by inoculation with the ACTH vaccine. Plasma cortisol concentrations in response to ACTH stimulation were reduced at 12 weeks, but not at 15 weeks, after the first inoculation.

CONCLUSIONS AND CLINICAL RELEVANCE

Inoculation of dogs with a recombinant ACTH vaccine resulted in the production of antibodies against the hormone. Anti-ACTH titers were initially high but were not sustained. The only detectable endocrine effect in treated dogs was a reduction in cortisol concentration in response to ACTH stimulation in 2 of 4 dogs at 12 weeks after the first inoculation. The effect of vaccine administration on the pituitary-adrenal system was subtle and transient.

Development of a formula to predict parathyroid carcinoma in patients with primary hyperparathyroidism

BACKGROUND

Cure of parathyroid carcinoma (PC) requires initial en bloc resection, including resection of all tumor-bearing tissue, with hemithyroidectomy and dissection of the central lymph node compartment. Unfortunately, no reliable preoperative criteria have yet been assessed to indicate a high likelihood of PC. Thus, the aim of the present study was to develop a formula to indicate preoperatively the presence of PC.

METHODS

A prospective database of 1,363 patients with primary hyperparathyroidism (pHPT) was screened for patients with PC. Age, gender, surgical procedures, laboratory data, and follow-up results were evaluated and compared to a group of patients with benign pHPT. Based on preoperative serum calcium (Ca) and parathyroid hormone (PTH) levels, as well as patients' age at the time of diagnosis, a formula was developed by a multivariate logistic model that estimates the individual risk for PC.

RESULTS

Between 1987 and 2008, 19 patients with PC were identified. Ca (3.8 ± 0.3 vs 2.9 ± 0.3 mmo/l; p = 0.0002) and PTH levels (1,250 ± 769 vs 194 ± 204 pg/ml; p = 0.0030) were significantly higher in patients with PC than in those with benign pHPT. Patients with PC were also significantly younger than patients with benign pHPT (48.9 ± 12.1 vs 59.1 ± 13.8 years; p < 0.05). With a ≥5 % probability that a given patient suffered from PC, the sensitivity and specificity to identify the disease were 100 and 30 %, respectively, with the new Ca, PTH, and age based logarithmic formula.

CONCLUSIONS

The new logarithmic formula can be used to calculate the individual risk for PC. If the calculated individual risk exceeds 5 %, en bloc resection seems to be justified to provide long-term cure in case of PC.

Diagnosis and management of parathyroid cancer

Parathyroid cancer is rare, but often fatal, as preoperative identification of malignancy against the backdrop of benign parathyroid disease is challenging. Advanced genetic, laboratory and imaging techniques can help to identify parathyroid cancer. In patients with clinically suspected parathyroid cancer, malignancy of any individual lesion is established by three criteria: demonstration of metastasis, specific ultrasonographic features, and a ratio >1 for the results of third-generation:second-generation parathyroid hormone assays. Positive findings for all three criteria dictate an oncological surgical approach, as appropriate radical surgery can achieve a cure. Mutation screening pinpoints associated conditions and asymptomatic carriers. Molecular profiling of tumour cells can identify high-risk features, such as differential expression of specific micro-RNAs and proteins, and germ line mutations in CDC73, but is unsuitable for preoperative assessment owing to the potential risks associated with biopsy. A validated, histopathology-based prognostic classification can identify patients in need of close follow-up and adjuvant therapy, and should prove valuable to stratify clinical trial cohorts: low-risk patients rarely die from parathyroid cancer, even on long-term follow-up, whereas 5-year mortality in high-risk patients is around 50%. This insight has improved the approach to parathyroid cancer by enabling risk-adapted surgery and follow-up.

Parathyroid carcinoma: update and guidelines for management

Parathyroid carcinoma is one of the rarest known malignancies that may occur sporadically or as a part of a genetic syndrome. It accounts for approximately 1% of patients with primary hyperparathyroidism. The majority (90%) of parathyroid cancer tumors are hormonally functional and hypersecrete parathyroid hormone (PTH). Thus, most patients exhibit strong symptomatology of hypercalcemia at presentation. Sometimes, it can be difficult to diagnose parathyroid cancer preoperatively due to clinical features shared with benign causes of hyperparathyroidism. Imaging techniques such as neck ultrasound and 99mTc sestamibi scan can help localize disease, but they are not useful in the assessment of malignancy potential. Fine needle aspiration (FNA) prior to initial operation is not recommended due to technical difficulty in differentiating benign and malignant disease on cytology specimens and the possible associated risk of tumor seeding from the needle track. Complete surgical resection with microscopically negative margins is the recommended treatment and offers the best chance of cure. Persistent or recurrent disease occurs in more than 50% of patients with parathyroid carcinoma. Surgical resection is also the primary mode of therapy for recurrence since it can offer significant palliation for the metabolic derangement caused by hyperparathyroidism and allows hypercalcemia to become more medically manageable. However, reoperation is rarely curative and eventual relapse is likely. Chemotherapy and external beam radiation treatments have been generally ineffective in the treatment of parathyroid carcinoma. Typically, these patients require repeated operations that predispose them to accumulated surgical risks with each intervention. In inoperable cases, few palliative treatment options exist, although treatment with calcimimetics can effectively control hypercalcemia in some patients. Most patients ultimately succumb to complications of hypercalcemia rather than from tumor burden or infiltration.

PTHrP induces autocrine/paracrine proliferation of bone tumor cells through inhibition of apoptosis

Giant Cell Tumor of Bone (GCT) is an aggressive skeletal tumor characterized by local bone destruction, high recurrence rates and metastatic potential. Previous work in our lab has shown that the neoplastic cell of GCT is a proliferating pre-osteoblastic stromal cell in which the transcription factor Runx2 plays a role in regulating protein expression. One of the proteins expressed by these cells is parathryroid hormone-related protein (PTHrP). The objectives of this study were to determine the role played by PTHrP in GCT of bone with a focus on cell proliferation and apoptosis. Primary stromal cell cultures from 5 patients with GCT of bone and one lung metastsis were used for cell-based experiments. Control cell lines included a renal cell carcinoma (RCC) cell line and a human fetal osteoblast cell line. Cells were exposed to optimized concentrations of a PTHrP neutralizing antibody and were analyzed with the use of cell proliferation and apoptosis assays including mitochondrial dehydrogenase assays, crystal violet assays, APO-1 ELISAs, caspase activity assays, flow cytometry and immunofluorescent immunohistochemistry. Neutralization of PTHrP in the cell environment inhibited cell proliferation in a consistent manner and induced apoptosis in the GCT stromal cells, with the exception of those obtained from a lung metastasis. Cell cycle progression was not significantly affected by PTHrP neutralization. These findings indicate that PTHrP plays an autocrine/paracrine neoplastic role in GCT by allowing the proliferating stromal cells to evade apoptosis, possibly through non-traditional caspase-independent pathways. Thus PTHrP neutralizing immunotherapy is an intriguing potential therapeutic strategy for this tumor.

Chromogranin A as potential target for immunotherapy of malignant pheochromocytoma

Currently, no effective treatment for malignant pheochromocytoma exists. The aim of our study was to investigate the role of chromogranin A (CgA) as a specific target molecule for immunotherapy in a murine model for pheochromocytoma. Six amino acid-modified and non-modified CgA peptides were used for dendritic cell vaccination. Altogether, 50 mice received two different CgA vaccination protocols; another 20 animals served as controls. In vitro tetramer analyses revealed large increases of CgA-specific cytotoxic T cells (CTL) in CgA-treated mice. Tumors of exogenous applied pheochromocytoma cells showed an extensive infiltration by CD8+ T cells. In vitro, CTL of CgA-treated mice exhibited strong MHC I restricted lysis capacities towards pheochromocytoma cells. Importantly, these mice showed strongly diminished outgrowth of liver tumors of applied pheochromocytoma cells. Our data clearly demonstrate that CgA peptide-based immunotherapy induces a cytotoxic immune response in experimental pheochromocytoma, indicating potential for therapeutic applications in patients with malignant pheochromocytoma.

Parathyroid cancer

Parathyroid cancer is an uncommon malignancy and rare cause of primary hyperparathyroidism (HPT) with a high morbidity and patient death in advanced cases usually resulting from intractable hypercalcemia. Inactivation of the HRPT2/CDC73 gene, encoding the putative tumor-suppressor protein parafibromin and discovered in the context of the hyperparathyroidism-jaw tumor (HPT-JT) syndrome, is a common, somatic event in most parathyroid cancers. Approximately 25% of patients with apparently sporadic parathyroid cancer carry germline HRPT2/CDC73 mutation. Germline DNA analysis for HRPT2/CDC73 mutation is recommended in all patients with parathyroid cancer because of the potential benefit for first-degree relatives, who should nevertheless undergo serum calcium screening. The histopathologic diagnosis of parathyroid cancer is nonspecific unless vascular, lymphatic, capsular, or soft tissue invasion is seen, or metastases are clinically evident. Immunohistochemical analysis of parathyroid tumors for loss of parafibromin expression offers promise as a diagnostic tool. En bloc tumor resection offers the highest chance of cure in patients with suspected parathyroid carcinoma. No adjuvant chemotherapy regimen has yet proven effective, and the role of local adjuvant radiotherapy is being evaluated. Metastatic disease can be palliated with surgical debulking. Medical therapy with the calcimimetic cinacalcet and bisphosphonates can ameliorate hypercalcemia in patients with inoperable disease.

Challenges and pitfalls in the management of parathyroid carcinoma: 17-year follow-up of a case and review of the literature

A 29-year-old man presented to his primary care physician with nausea, severe weight loss and muscle weakness. He had a hard, fixed neck swelling. He was severely hypercalcaemic with 10-fold increased parathyroid hormone (PTH) concentrations. A diagnosis of primary hyperparathyroidism was established and the patient was referred for parathyroidectomy. At neck exploration, an enlarged parathyroid gland with invasive growth into the thyroid gland was found and removed, lymph nodes were cleared and hemithyroidectomy was performed. A suspected diagnosis of parathyroid carcinoma was confirmed histologically. Serum calcium and PTH levels normalised post-operatively, but hyperparathyroidism recurred within 3 years of surgery. Over the following 17 years, control of hypercalcaemia represented the most difficult challenge despite variable success achieved with repeated surgical interventions, embolisations, radiofrequency ablation of metastases and treatment with calcimimetics, bisphosphonates and haemodialysis using low-dialysate calcium. In this paper, we report the challenges and pitfalls we encountered in the management of our patient over nearly two decades of follow-up and review recent literature on the topic.

Focus on parathyroid carcinoma

Parathyroid carcinoma is a malignant neoplasm affecting 05-2 per cent of all patients with primary hyperparathyroidism that was first described by de Quevain in 1904. To day it continues to defy diagnosis and treatment. It is difficult to diagnose in part because of its rarity, lack of definitive diagnostic markers and overlapping clinical features of benign primary hyperparathyroidism. As a result initial surgical treatment is inadequate essentially leading to disease recurrence where complete cure is unlikely. En bloc surgical resection remains the only curative treatment, and high priorities are improving diagnostic methods, and clinical staging for resection once the disease is suspected. Margin status at resection is related to prognosis. Thus, a trend towards aggressive surgical management has improved outcomes. The recurrence rate of parathyroid carcinoma is as high as 80% with survival rates <50% at 10 years. Results of chemotherapy are disappointing. However, recent trials using radiation therapy are promising, but require further study.

Parathyroid carcinoma

Parathyroid carcinoma is a rare tumor that is prone to recurrence and poor local-regional control. Despite advances in technologies that have shown promise for accurate diagnosis, the mainstay of initial diagnosis remains pathologic analysis and clinical assessment. A surgeon's intraoperative analysis is important in managing patients with parathyroid carcinoma. If parathyroid carcinoma is suspected intraoperatively, a more aggressive surgical strategy should be implemented. This article presents a case series and summary of the existing parathyroid carcinoma literature.

Advances in cellular therapy for the treatment of thyroid cancer

Up to now, there are no curative therapies available for the subset of metastasized undifferentiated/anaplastic thyroid carcinomas. This review describes the possible use of immunocompetent cells which may help to restore the antitumor immune recognition for treating an existing tumor or preventing its recurrence. The most prominent experimental strategy is the use of dendritic cells (DCs) which are highly potent in presenting tumor antigens. Activated DCs subsequently migrate to draining lymph nodes where they present antigens to naïve lymphocytes and induce cytotoxic T cells (CTL). Alternatively to DC therapy, adoptive cell transfer may be performed by either using natural killer cells or ex vivo maturated CTLs. Within this review article we will focus on recent advances in the understanding of anti-tumor immune responses, for example, in thyroid carcinomas including the advances which have been made for the identification of potential tumor antigens in thyroid malignancies.

Parathyroid carcinoma

Parathyroid carcinoma is a rare endocrine malignancy. The reported incidence is from 0.5 to 5% of primary hyperparathyroidism cases in various series. The cause is unknown, but clinical correlations with different genetic syndromes exist. Mutations in the HPRT2 gene seem to play a significant role in the pathogenesis of this disease. Men and women are equally affected, usually in the fourth or fifth decade of life. Most patients will present with signs and symptoms of hypercalcaemia. Cases of non-functioning carcinoma are exceedingly rare. Surgical resection is the most effective method of treatment and palliation. A significant proportion of patients will experience recurrence, and will need further surgical and, eventually, medical management of hypercalcaemia. The disease is progressive but slow growing. Most patients will require multiple operations to resect recurrent disease. The main cause of morbidity and mortality is the sequela of uncontrolled chronic hypercalcaemia rather than tumour burden. The current paper will review the epidemiology, pathogenesis, clinical presentation and diagnostic work-up of this disease. Surgical management in different scenarios is reviewed in detail, followed by other types of treatment and management of incurable disease.

Clinical presentation, staging and long-term evolution of parathyroid cancer

BACKGROUND

Parathyroid cancer is rare and often fatal. This review provides an in-depth analysis of 330 clinical cases reported in detail. These data are used to inform a proposal for a hitherto lacking TNM staging system.

MATERIALS AND METHODS

All case reports or series with sufficient case details of parathyroid cancer were identified from PubMed, and data were analyzed using SPSS.

RESULTS

Of 330 patients, 117 (35%) died of disease and 207 (63%) experienced recurrence in a total of 2007 follow-up years and a mean length of follow-up of 6.1 years. Histopathology findings rather than biochemical or clinical features predict outcome. In univariate analysis, survival and recurrence rates are significantly influenced by gender (male relative risk [RR] 1.7, 95% confidence interval [95% CI] 1.0-2.7, P < .01), and presence of vascular invasion (RR 4.3, 95% CI 1.1-17.7, P < .01), or lymph node metastases (RR 6.2, 95 %CI 0.9-42.9, P < .001). Failure to perform oncological surgery carries a high risk for recurrence and death (local versus en bloc resection RR 2.0, CI 1.2-3.2, P < .01) as for redo surgery. Staging by a novel anatomy-based TNM system identifies significant outcome variation as to recurrence and death. Separation of patients into low and high risk identifies a 3.5-7.0 fold higher risk of recurrence and death (P < .01) for the high-risk group. Distant metastases predominantly target mediastinum and lung.

CONCLUSION

Understaging and undertreatment are shown to contribute to high recurrence rates and death toll. To improve outcome, en bloc resection including central lymph node dissection should be the minimal surgical approach in any patient with suspected parathyroid cancer.

[Primary hyperparathyroidism in special situations: multiple endocrine neoplasia syndromes and parathyroid cancer]

Primary hyperparathyroidism (PHP) is a known endocrine disorder. Many years ago, the most frequent forms of clinical presentation were symptomatic renal or skeletal disease with moderate or severe hypercalcemia; however, currently, most patients have few symptoms and mild hypercalcemia. The last NIH Workshop on Asymptomatic PHP developed criteria for the management of this disease. Multiple endocrine neoplasia (MEN) types 1 and 2 are two genetic syndromes caused by different types of molecular abnormalities. PHP is the most common manifestation of MEN-1 and is the last feature to appear in MEN 2A. Parathyroid carcinoma (PC) is a rare neoplasm and an uncommon cause of parathyroid hormone (PTH)-dependent hypercalcemia. In this report, the treatment of PHP in MEN syndrome and PC are reviewed. Special attention is paid to a new class of drugs called "calcimimetics", which are powerful compounds that may be highly useful in the treatment of both conditions.

Identifying tumor antigens in endocrine malignancies

Tumor antigens are surface molecules that are mostly cancer specific, often overexpressed and recognized by the immune system. Therefore, identifying tumor antigens is of key importance for developing new immunotherapies for incurable cancers. For endocrine malignancies, several different tumor-associated antigens have been described, including polypeptide hormones and/or vesicle-associated antigens in Th1-mediated autoimmune diseases. Other antigens have been identified by screening tumor DNA libraries. Furthermore, vaccination studies in humans and animal models have revealed a tumor-antigen-specific immunity and clinical responses with reduced tumor size. Here, we provide an overview of the recent progress achieved in identifying tumor antigens and predict how this knowledge can be used in the future for developing anti-tumor vaccinations.

Amino acid-modified calcitonin immunization induces tumor epitope-specific immunity in a transgenic mouse model for medullary thyroid carcinoma

Up to now, no relevant tumor antigen has been identified in medullary thyroid carcinoma (MTC). The aim of the present study was to prove the concept of an immunization with an amino acid-modified calcitonin (CT) for the treatment of MTC in a transgenic mouse model. Amino acid-modified (human) CT has been chosen for vaccination because of its higher binding affinity to the murine H2-Kb-MHC molecule. Mice were immunized over 6 months with monthly injections of amino acid-modified CT-pulsed dendritic cells. For enumeration of tumor epitope-specific CD8+ cytotoxic T cells, tetramer analyses were performed. CT peptide-treated mice revealed a mean 0.73 +/- 0.45 and 0.91 +/- 0.59% positive cells, depending on the two tetramers tested, whereas no increase was seen in control protein-immunized mice (0.08-0.12% tetramer-positive cells). Importantly, the subset of CT-specific CD8+ T cells also showed a high expression of interferon-gamma. In line with these results, CT-immunized mice also showed an intratumor infiltration with CD8+ T lymphocytes. Importantly, we also found a diminished tumor outgrowth of -57% and a decrease of the serum CT levels (2.0 +/- 0.1 pg/ml) compared with control protein-immunized Ret/Cal mice (3.0 +/- 0.4 pg/ml). In summary, we show that amino acid-modified CT is recognized from the immune system leading to a specific antitumor immune response and a diminished tumor outgrowth in transgenic MTC mice. The results are of potential importance because they might be applicable to patients with metastatic spread of a MTC.

Functional reconstruction and synthetic mimicry of a conformational epitope using CLIPS technology

This paper describes immunization studies with CLIPS-constrained peptides covering only the major part (beta3-loop) of a structurally complex antigenic site on human Follicle Stimulating Hormone beta-subunit (FSH-beta). In cases where linear and SS-constrained peptides fail, the CLIPS-constrained peptides generate polyclonal antibodies with high neutralizing activity for hFSH. The sera were shown to be specific for hFSH over human Luteinizing Hormone (hLH) and human Chorionic Gonadotropin (hCG). ELISA-competition studies and circular dichroism (CD)-measurements illustrate clearly that activity of the peptides in antibody binding and generation relates directly to precise and appropriate fixation of the peptide conformation. Design of the CLIPS-peptides was entirely based on epitope mapping studies with two neutralizing anti-hFSH mAbs. Both mAbs were shown to bind to a conformational epitope located at the top of the beta1-beta3-loop covering the amino acid sequences Y58-P77 (beta3-loop). The results described in this paper show that CLIPS-constrained peptides covering the Y58-P77 sequence provide the minimally required structural entity necessary to generate reproducibly sera with high hFSH-neutralizing activity.

Use of cinacalcet HCl to achieve the recommended targets of bone metabolism in a patient with therapy-resistant renal hyperparathyroidism

We report on a patient with end-stage renal disease and severe progressive secondary hyperparathyroidism, whose condition failed to respond to conventional pharmacologic or surgical interventions. Although immunotherapy produced a partial response, it failed to decrease serum parathyroid hormone to the levels recommended by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative clinical practice guidelines. Treatment with a new calcimimetic agent, cinacalcet HCl (Mimpara, Amgen, Munich, Germany), resulted in a rapid decline in elevated parathyroid hormone levels, near normalization of other laboratory markers of bone metabolism, improvement in mobility and skeletal pain caused by renal osteodystrophy, and an increase in body weight.

Multiglandular parathyroid carcinoma: a case report and brief review

A 53-year-old man with no past medical history was admitted with complaints of hematuria, flank and abdominal pain of one week duration. He also complained of an enlarging new neck mass one month before presentation. The laboratory assessment showed a calcium level of 17.3 mg/dL (normal 8.5-10.5 mg/dL), serum albumin 2.9 g/dL (normal 3.0-5.0 g/dL), serum creatinine 3.4 mg/dL (normal 0.5-1.2 mg/dL). A neck ultrasound showed a complicated left neck mass. He was hydrated for one week with improvement in his labs, showing a decrease in serum calcium to 9.3 mg/dL and a serum creatinine of1.8 mg/dL. He underwent a total thyroidectomy and parathyroidectomy. The pathology showed multiglandular parathyroid carcinoma. It is important for the physician and surgeon dealing with primary hyperparathyroidism to look for parathyroid carcinoma. A better knowledge and understanding of this condition would aid in early diagnosis and possibly increase the survival rate.

Use of pre-operative Tc99m-Sestamibi scintigraphy and intraoperative parathyroid hormone monitoring to eliminate neck exploration in mediastinal parathyroid adenocarcinoma

A 66-year-old white woman was found to have an elevated serum calcium and parathyroid hormone (PTH) on routine health evaluation. Physical examination was unremarkable as was ultrasonography of the neck. A sestamibi parathyroid scan revealed abnormal uptake in the anterior mediastinum. Computed tomography of the chest demonstrated an anterior mediastinal mass compatible with a parathyroid adenoma but no neck masses. The patient underwent mediastinoscopy that was converted to a median sternotomy to fully access the mass. The mass was completely resected with surrounding thymus gland. Frozen section confirmed that excised tissue was parathyroid gland in origin. An intraoperative PTH obtained 20 minutes after specimen removal showed a decrease of more than 50% from preoperative levels. The strategy for initial surgery for hyperparathyroidism when a sestamibi scan is "positive" in the mediastinum (only) is a point of some controversy. Traditional recommendations have been to "clear the neck" of abnormal parathyroid tissue before undertaking a more morbid sternotomy. Mediastinoscopy was attempted to remove the mediastinal lesion and to avoid a sternotomy. Preoperative Tc99m sestamibi scintigraphy, frozen section histology, and intraoperative PTH monitoring permitted the authors to conclude that neck exploration was unnecessary.

Correlation between Clinical and Histological Findings in Parathyroid Tumors Suspicious for Carcinoma

Carcinoma of the parathyroid is a rare malignancy that can be cured surgically if the proper diagnosis and treatment is given initially. Arriving to the clinical suspicion of a malignancy preoperatively is by far the most important step for a good prognosis. Our goal is to review the correlation between clinical and final histopathological findings that can arouse the suspicion of such malignancy and their true predictive value in the diagnosis. All patients that underwent surgical removal of the parathyroid mass between March of 1992 and March of 2003 were reviewed retrospectively at Providence Hospital and Medical Centers. Among 168 patients who underwent parathyroid excision, 14 (8.3%) had hyperplasia of the parathyroid, 121 (72%) had benign adenoma, 25 (14.8%) had other benign lesions, and 8 (4.7%) patients had primary carcinoma of the parathyroid confirmed by pathology. Our mean serum calcium level was 11.57 mg/dL, which was lower than the mean level (12 mg/dL) for benign hyperparathyroidism. The mean tumor size was 2.18 cm, smaller than the proposed for malignant criteria, and none of the eight patients (0%) had any symptoms of hypercalcemia at the time of diagnosis. Seven of eight patients (87.5%) had frank signs of invasion together with other histological features, and two patients had associated papillary carcinoma of the thyroid. Five patients from our series did not meet clinical criteria for malignancy (tumor size > 3 cm, palpable mass, and serum calcium > 14 mg/dL), but had undisputable histological findings (high mitotic pattern, fibrous trabeculae, capsular invasion, vascular invasion, and nodular involvement). On the other hand, 17 patients with benign histology had tumors greater than 3 cm, and an additional 18 had palpable masses on physical examination. We believe that these patients need to be followed closely. The patients with diagnosis of parathyroid carcinoma, their kindred, and those with large adenomas may benefit from genetic screening for HRTP2 gene mutations in search of early detection of tumors suspicious for malignancy. This is based on the fact that we did not find correlation between the clinical presentation and the histological features in our patients with proven malignancy.

Intracranial metastatic parathyroid carcinoma: case report

BACKGROUND

Although parathyroid carcinoma is not frequent, it is a slowly progressive disease characterized by frequent recurrences. A review of the literature revealed only 2 other cases of intracranial metastatic parathyroid carcinoma. We present here the case of cerebral metastases from parathyroid carcinoma that could be treated successfully.

CASE DESCRIPTION

This 61-year-old Japanese woman presented to our institute with a complaint of right lower-extremity weakness after hemiconvulsion. She had undergone a parathyroidectomy for parathyroid carcinoma 18 years earlier. Lung metastasis was also detected 6 years earlier, and she has been dialyzed twice a month after chemotherapy. Computed tomographic scans demonstrated 2 enhancing right frontal tumors. After resection of the intracranial metastases, her right hemiparesis and secondary hyperparathyroidism resolved.

CONCLUSIONS

This case report supports aggressive surgical management to eliminate all parathyroid hormone-secreting malignant tissue and prevent metabolic complications.

Parathyroid carcinoma

BACKGROUND

Parathyroid carcinoma is a rare malignancy affecting 0.5-5 per cent of all patients with primary hyperparathyroidism. This article reviews the literature on the pathogenesis, pathology, clinical features, diagnosis and management of parathyroid carcinoma.

METHODS

A Medline search was performed and all relevant English language articles published between 1970 and 2005 were retrieved. The search words included 'parathyroid carcinoma', 'pathology', 'genetics', 'management' and 'radiotherapy'. Secondary references were obtained from key articles.

RESULTS AND CONCLUSION

The exact aetiology of parathyroid carcinoma remains obscure. Recently, the HRPT2 gene has been implicated in its pathogenesis and may prove to be a genetic target in future. Surgical resection is the accepted 'gold standard'. There is now a growing consensus on the use of adjuvant radiotherapy as it has been shown to provide a survival benefit.

Results of iterative surgery for persistent and recurrent parathyroid carcinoma

BACKGROUND AND AIMS

Parathyroid carcinoma (PC) is a rare cause of primary hyperparathyroidism. Surgery is the only effective treatment; re-operations are often required, because recurrences occur in most of the cases. The aim of this retrospective study was to analyse the rate of biochemical cure, clinical relief, sensitivity of localizing studies and morbidity after re-operations.

PATIENTS AND METHODS

From January 1980 to December 2000, 19 patients underwent surgery for PC. PC persisted or recurred in all cases. Fourteen re-operations were performed in six patients.

RESULTS

Twelve re-operations at loco-regional site and two pulmonary metastasectomies were performed. Iterative surgery achieved a symptomatic relief in 86% of cases and a transient biochemical remission only in one patient, but significantly reduced parathormone and calcemia. The sensitivity of scintigraphy, CT and ultrasonography was 86, 79 and 100%, respectively.

CONCLUSION

When recurrences occur, complete cure of PC is unlikely, despite re-operations. Iterative surgery is associated with some morbidity and never achieves a definitive cure, but provides significant clinical and biochemical palliation. Localizing studies are mandatory but do not detect all recurrences.

Parathyroid Cancer, a Continued Diagnostic and Therapeutic Dilemma: Report of Four Cases and Review of the Literature

Parathyroid cancer presents a diagnostic challenge as a rare endocrine malignancy usually not recognized preoperatively and often not conclusively identified intraoperatively. We examined a cluster of parathyroid cancers treated at University of Louisville-affiliated hospitals during a 5-year interval. Clinical and histologic data from patient records at University Surgical Associates, the University of Louisville Hospital, Norton Hospital, and the Louisville Veterans Administration Medical Center in Louisville, KY were retrospectively reviewed. During the study interval surgical exploration of the neck was undertaken on 175 patients with primary hyperparathyroidism; four parathyroid malignancies (2%) were identified. Three of the four patients exhibited symptomatic hyperparathyroidism with very high diagnostic calcium and parathormone levels. All patients had multiple coexisting diseases and two had undergone previous parathyroid surgery. Sestamibi scan localized the lesion in two patients, ultrasound was used in one patient, and a positron emission tomography scan was needed to identify the lesion in the fourth. Intraoperative findings varied from multiple nodules involving the thyroid and paratracheal nodules to otherwise normal-appearing enlarged parathyroid gland. External pathologic review was needed to conclusively establish the diagnosis in all cases, even though initial histologic analysis was suggestive of malignancy. All patients are alive, well, and free of disease. This rarely occurring malignancy may be suggested by very high preoperative calcium parathormone levels. Intraoperative and histologic findings are often inconclusive resulting in therapeutic decisions made by the operating surgeon on the basis of limited or incomplete information.

Dendritic cell vaccination: new hope for the treatment of metastasized endocrine malignancies

Dendritic cells (DCs) are antigen-presenting cells that are involved in the induction of primary immune responses. The unique ability of DCs to activate naive and memory CD4+ and CD8+ T cells suggests that they could be used for the induction of a specific antitumour immunity. In the past few years, several in vitro and in vivo studies in rodents and humans have demonstrated that immunizations with DCs pulsed with tumour antigens result in protective immunity and rejection of established tumours in various malignancies. Here, we focus on recent results of how DCs regulate immune responses that are important for generating antitumour cytotoxic T cells, and summarize clinical vaccination trials for the treatment of endocrine and nonendocrine carcinomas. Preliminary results suggest that DC vaccines might be novel tools for antitumour immunotherapies to treat chemotherapy-resistant and radioresistant endocrine cancers, such as metastasized medullary thyroid carcinomas and other neuroendocrine carcinomas.

Hypercalcaemia, parathyroid hormone-related protein and malignancy

Hypercalcaemia is the most common serious metabolic complication of malignancy. Recent advances have significantly increased our understanding of the pathophysiology of hypercalcaemia of malignancy and revealed the importance of parathyroid hormone-related protein (PTHrP) in a wide range of physiological and pathological processes. This review examines the pathophysiology of hypercalcaemia of malignancy, focusing on the role of PTHrP before discussing further pathological and physiological processes in which PTHrP may be implicated, and the impact of this knowledge on the management of malignant disease.

Association between coeliac disease, epilepsy and brain atrophy

Patients with epilepsy and posterior cerebral calcifications have an increased risk of coeliac disease (CD). The occurrence of this syndrome and the overall risk of CD and epilepsy remain still poorly understood. This study presents the prevalence of CD, brain atrophy, and cerebral calcifications in patients with epilepsy of unknown aetiology. The medical records of 900 consecutive adult patients with epilepsy diagnosis were reviewed. The occurrence of CD in living patients with epilepsy of unknown aetiology (n = 199) was investigated; all patients without previously known CD were asked for serological screening for the disease and the diagnosis was verified with small bowel biopsy. The presence of occipital calcifications and brain atrophy in all available CT scans (n = 130) was evaluated. Five of 199 cases had prior history of CD. The prevalence of definite CD in the patients was 2.5% (5/199), which is significantly higher that the current prevalence of CD in our area (0.27%). Antibody testing and small bowel biopsy in positive cases failed to increase prevalence of CD. Eleven (8.5%) patients had intracerebral calcifications and 3 of them posterior calcifications; all 11 had negative screening results for CD. Four (80%) patients with definite CD had supratentorial brain atrophy compared with 33 (26%) of 125 patients without CD. Prevalence of CD was increased among patients with epilepsy of unknown aetiology, but the combination of CD, epilepsy and intracranial posterior calcifications was rare in Finnish adult epilepsy population.