Casos clínicos-Cáncer paratiroideo como causa de fractura y osteoporosis secundaria en el adulto mayor

Introducción. El carcinoma paratiroideo es infrecuente y más en población geriátrica, afecta el metabolismo óseo y es enmascarado por patologías comunes que causan fracturas de bajo impacto.

Objetivo. Ilustrar el cáncer paratiroideo dentro del estudio de las fracturas patológicas y la osteoporosis secundaria, para favorecer el diagnóstico temprano en el adulto mayor.

Presentación del caso. Mujer de 71 años con osteoporosis presentó fractura de fémur mientras caminaba. Se evidenció síndrome constitucional, anemia, nefrolitiasis y lesiones osteolíticas; se consideró metástasis óseas versus tumores pardos. Se descartaron neoplasias ginecológicas frecuentes y tumores de células plasmáticas. Estudios tomográficos mostraron nódulo pulmonar y nódulo tiroideo (4 cm), el perfil fosfocálcico indicó hiperparatiroidismo primario, gammagrafía paratiroidea Tc99 MIBI fue negativa. Previa dosis de zoledronato, se realizó exploración de paratiroides, hemitiroidectomía izquierda en bloque y paratiroidectomía superior derecha. Histología e inmunohistoquímica de masa cervical reportó carcinoma de paratiroides. Seguimiento posquirúrgico indicó paratohormona y calcio elevado, e imágenes con metástasis pulmonares.

Discusión y conclusión. Las fracturas por osteoporosis son frecuentes, pero ante fracturas atípicas y/o puntaje Z?-2, se deben considerar causas tumorales, infecciosas y evaluación temprana del metabolismo fosfocálcico. El cáncer de paratiroides es más frecuente alrededor de los 50 años, pero puede presentarse a cualquier edad; en adultos mayores comparte características clínicas con entidades prevalentes como osteoporosis posmenopáusica, nefrolitiasis y nódulo tiroideo. El cáncer paratiroideo tiene un espectro clínico amplio y debe ser una posibilidad diagnóstica ante fracturas patológicas o hiperparatiroidismo grave, incluso en ausencia de lesión paratiroidea en un Tc99 MIBI o en presencia de patología tiroidea. El abordaje quirúrgico temprano es la mejor opción terapéutica, y el diagnóstico histológico debe apoyarse en inmunohistoquímica por falta de características citológicas específicas del cáncer paratiroideo.

Cetani F, Pardi E, Marcocci C. Parathyroid Carcinoma. In: Frontiers of hormone research [Internet]. 2019 [cited 2019 Jan. 26]. Pp. 63-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30641523. https://doi.org/10.1159/000491039

Benchafai I, Afani L, Errami N, Hemmaoui B, Errihani H, Benariba F. Giant parathyroid carcinoma: diagnostic difficulties and therapeutic strategies. Pan Afr Med J [Internet]. 2017 [cited 2019 Jan. 19]; 26:211. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28690726.

https://doi.org/10.11604/pamj.2017.26.211.8770

Bilezikian JP, Bandeira L, Khan A, Cusano NE. Hyperparathyroidism. Lancet (London, England) [Internet];. 2018 Jan. 13 [cited 2019 Jan. 26; 391(10116):168-78. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28923463. https://doi.org/10.1016/S0140-6736(17)31430-7

Herrera AA, Aranda P, Díaz JA. Cáncer de paratiroides: revisión de literatura. Rev Española Enfermedades Metabólicas Óseas [Internet]. 2007 nov. 1 [cited 2019 Apr. 28]; 16(6):124-9. Available from: https://www.elsevier.es/es-revista-reemo-70-articulo-cancer-de-paratiroides-revision-de-13111857. https://doi.org/10.1016/S1132-8460(07)73511-0

Mendoza-Zubieta V, Zamudio-Villarreal JF, Peña-García JF, Marín-Méndez A, Martínez-Martínez L, Mercado-Atri M. Primary hyperparathyroidism: A report of 67 cases.The experience of 5 years at the IMSS Centro Médico Nacional Siglo XXI Specialties Hospital. Cir Cir [Internet]. 2003 [cited 2019 Jan. 19]; 71(5):363-8. Available from: http://www.medigraphic.com/cgi-bin/new/resumenI.cgi?IDARTICULO=596

Ríos SL, Sapunar ZJ, Roa EI. Hiperparatiroidismo primario con compromiso esquelético grave: un caso de carcinoma paratiroideo. Rev Med Chil [Internet]. 2005 en. [citado 2019 en. 19]; 133(1):77-81. Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100010&lng=en&nrm=iso&tlng=en

https://doi.org/10.4067/S0034-98872005000100010

Rocha AL, Suazo LC, González PM, Lee Ch K, Rossel DG. Hiperparatiroidismo primario y cáncer de paratiroides: Caso clínico. Rev Chil Cir [Internet]. 2010 oct. [citado 2019 en. 19]; 62(5):512-5. Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-40262010000500016&lng=en&nrm=iso&tlng=en

https://doi.org/10.4067/S0718-40262010000500016

Hernández-Sánchez V, Silva-Ortiz J, Martínez-Lara E, Díaz-Villanueva D, Chávez Martínez MÁ. Carcinoma de la glándula paratiroides. Reporte preliminar y descripción de tres casos. Rev Sanid Milit [Internet]. 2003 oct. 31 [citado 2019 en. 19]; 57(5):313-7. Available from: http://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=75147

Puerta JD, Aristizabal H. Carcinoma de Paratiroides. Rev Colomb Cirugía [Internet].1992 [citado 2019 abr. 20]; 7(3). Available from: https://encolombia.com/medicina/revistas-medicas/cirugia/vc-073/carcinoma-paratiroides/

Acuña-Hernández M, Morales T, González A, Sarmiento J. Carcinoma de paratiroides: hallazgo en gammagrafía con 99mTc- Sestamibi - Alasbimn Journal. Alasbimn J [Internet]. 2018 [cited 2019 Jan. 19]; ISSN: 0717. Available from: http://www.alasbimnjournal.net/a/184

Latorre G, García J, Castelblanco J. Acta Médica Colombiana. Acta Médica Colomb [Internet]. 1990; 15(5):323-8. Available from: http://www.actamedicacolombiana.com/cont.php?id=98&id2=922

Laura-Asillo E, Román-Pérez F, Villarín-Castro A, Hernández-Sanz A. Fractura atípica de fémur secundaria al uso de bifosfonatos. Laura-Asillo EG, Román Rev Clínica Med Fam [Internet]. 2017; 10(2):141-4. Available from: www.redalyc.org/articulo.oa?id=169652040009

Tencer AF, Johnson KD. Biomechanics in orthopaedic trauma [Internet]. London: Martin Dunitz. 1994. 300 pp. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0268003396900376

García J, Guerrero ÉA, Terront A, Molina JF, Pérez C, Jannaut MJ, et al. Costos de fracturas en mujeres con osteoporosis en Colombia. Acta Medica Colomb [Internet]. 2014 [cited 2019 Apr. 28]; 39(1):46-56. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-24482014000100011

Palacios S, Christiansen C, Sánchez-Borrego R, Gambacciani M, Hadji P, Karsdal M, et al. Recommendations on the management of fragility fracture risk in women younger than 70 years. Gynecol Endocrinol [Internet]. 2012 Oct. 7 [cited 2019 Jan. 23]; 28(10):770-86. Available from: https://www.academia.edu/17509439/Recommendations_on_the_management_of_fragility_fracture_risk_in_women_younger_than_70_years

https://doi.org/10.3109/09513590.2012.679062

Watts NB. Postmenopausal Osteoporosis: A Clinical Review. J Women's Heal [Internet]. 2018 sept. [cited 2019 Jan. 26]; 27(9):1093-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29583083

https://doi.org/10.1089/jwh.2017.6706

IOF - International Osteoporosis Foundation. Hip Fracture Incidence Map [Internet]. Data y Publications. 2019 [cited 2019 Apr. 28]. Available from: https://www.iofbonehealth.org/facts-and-statistics/hip-fracture-incidence-map

Jaller-Raad JJ, Jaller-Char JJ, Lechuga-Ortiz JA, Navarro-Lechuga E, Johansson H, Kanis JA. Incidence of Hip Fracture in Barranquilla, Colombia, and the Development of a Colombian FRAX Model. Calcif Tissue Int [Internet]. 2013 Jul. 8 [cited 2019 Apr. 28]; 93(1):15-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23471427

https://doi.org/10.1007/s00223-013-9717-7

Roche JJW, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ [Internet]. 2005 Dec. 10 [cited 2019 Apr. 28]; 331(7529):1374. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16299013

https://doi.org/10.1136/bmj.38643.663843.55

Vaishya R, Agarwal AK, Banka PK, Vijay V, Vaish A. Insufficiency Fractures at Unusual Sites: A Case Series. J Orthop case reports. 2017; 7(4):76-9.

Miller T, Kaeding CC, Flanigan D. The classification systems of stress fractures: A systematic review. Phys Sportsmed. 2011; 39(1):93-100.

https://doi.org/10.3810/psm.2011.02.1866

Mirza F, Canalis E. Secondary osteoporosis: pathophysiology and management. Eur J Endocrinol [Internet]. 2015 Sep. [cited 2019 May. 26]; 173(3):R131-51. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4534332

https://doi.org/10.1530/EJE-15-0118

LeBlanc ES, Rosales AG, Black DM, Genant HK, Dell RM, Friess DM, et al. Evaluating Atypical Features of Femur Fractures: How Change in Radiological Criteria Influenced Incidence and Demography of Atypical Femur Fractures in a Community Setting. J Bone Miner Res [Internet]. 2017 Nov. 1 [cited 2019 Apr. 23]; 32(11):2304-14. Available from: http://doi.wiley.com/10.1002/jbmr.3221

https://doi.org/10.1002/jbmr.3221

Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, et al. Atypical subtrochanteric and diaphyseal femoral fractures: Second report of a task force of the American society for bone and mineral research. Vol. 29, Journal of Bone and Mineral Research. 2014. Pp. 1-23.

https://doi.org/10.1002/jbmr.1998

Adler RA, El-Hajj Fuleihan G, Bauer DC, Camacho PM, Clarke BL, Clines GA, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2016 Jan. 1; 31(1):16-35.

https://doi.org/10.1002/jbmr.2708

Pedrazzoni M, Giusti A, Girasole G, Abbate B, Verzicco I, Cervellin G. Atypical femoral fractures in Italy: a retrospective analysis in a large urban emergency department during a 7-year period (2007-2013). J Bone Miner Metab [Internet]. 2017 Sep. 9 [cited 2019 Jan. 26]; 35(5):562-70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27830385

https://doi.org/10.1007/s00774-016-0790-7

Miura T, Kijima H, Ishikawa N, Ebina T, Tani T, Chida S, et al. Comparison of Atypical and Osteoporotic Femoral Shaft Fractures in the Elderly: A Multicenter Study. Adv Orthop [Internet]. 2018 [cited 2019 Jan. 26]; 2018:1-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29862085

https://doi.org/10.1155/2018/1068053

NIH Consensus Development Panel on Osteoporosis Prevention Diagnosis and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA [Internet]. 2001;285(6):785-95. Available from: http://jama.jamanetwork.com/

https://doi.org/10.1001/jama.285.6.785

Wang A, Yuan L. Primary hyperparathyroidism. Vol. 7, Clinical Case Reports. Wiley-Blackwell Publishing Ltd. 2019. Pp. 849-50.

https://doi.org/10.1002/ccr3.2035

Cetani F, Pardi E, Borsari S, Viacava P, Dipollina G, Cianferotti L, et al. Genetic analyses of the HRPT2 gene in primary hyperparathyroidism: Germline and somatic mutations in familial and sporadic parathyroid tumors. J Clin Endocrinol Metab. 2004 Nov.;89(11):5583-91. https://doi.org/10.1210/jc.2004-0294

DeLellis RA. Challenging Lesions in the Differential Diagnosis of Endocrine Tumors: Parathryoid Carcinoma. Endocr Pathol [Internet]. 2008 Dec. 5 [cited 2019 Jan. 26];19(4):221-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19058032

https://doi.org/10.1007/s12022-008-9050-2

Cabané TP, Gac EP, Araya CD, Amat VJ, Rodríguez FF, Moyano SL, et al. Detección inmunohistoquímica de parafibromina en patología de paratiroides. Rev Chil cirugía [Internet]. 2013 febr. [citado 2019 en. 19];65(1):20-4. Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-40262013000100004&lng=en&nrm=iso&tlng=en

https://doi.org/10.4067/S0718-40262013000100004

Gill AJ, Lim G, Cheung VKY, Andrici J, Perry-Keene JL, Paik J, et al. Parafibromin-deficient (HPT-JT Type, CDC73 Mutated) Parathyroid Tumors Demonstrate Distinctive Morphologic Features. Am J Surg Pathol [Internet]. 2019 Jan. [cited 2019 Aug 9];43(1):35-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29324469

https://doi.org/10.1097/PAS.0000000000001017

Truran PP, Johnson SJ, Bliss RD, Lennard TWJ, Aspinall SR. Parafibromin, Galectin-3, PGP9.5, Ki67, and Cyclin D1: Using an Immunohistochemical Panel to Aid in the Diagnosis of Parathyroid Cancer. World J Surg [Internet]. 2014 Nov. 8 [cited 2019 Aug. 16];38(11):2845-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25002250

https://doi.org/10.1007/s00268-014-2700-2

Kumari N, Chaudhary N, Mishra P, Agarwal A, Krishnani N. Association of Biochemical and Histological Features with Parafibromin, Galectin-3, and PGP9.5 in Parathyroid Neoplasms. World J Endocr Surg [Internet]. 2019 Apr.; 11(1):6-14. Available from: https://www.wjoes.com/doi/10.5005/jp-journals-10002-1246

https://doi.org/10.5005/jp-journals-10002-1246

Wei CH, Harari A. Parathyroid Carcinoma: Update and Guidelines for Management. Curr Treat Options Oncol [Internet]. 2012 Mar. 12 [cited 2019 Jan. 25];13(1):11-23. Available from: http://link.springer.com/10.1007/s11864-011-0171-3

https://doi.org/10.1007/s11864-011-0171-3

Schantz A, Castleman B. Parathyroid carcinoma.A study of 70 cases. Cancer [Internet]. 1973 Mar. 1 [cited 2019 Jan. 19];31(3):600-5. Available from: https://doi.org/10.1002/1097-0142(197303)31:3%3C600::AID-CNCR2820310316%3E3.0.CO;2-0

https://doi.org/10.1002/1097-0142(197303)31:3<600::AID-CNCR2820310316>3.0.CO;2-0

Khan A, Tischler AS, Patwardhan NA, DeLellis RA. Calcitonin immunoreactivity in neoplastic and hyperplastic parathyroid glands: an immunohistochemical study. Endocr Pathol [Internet]. 2003 [cited 2019 Aug. 16];14(3):249-55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14586070

https://doi.org/10.1007/s12022-003-0017-z

Wang P, Xue S, Wang S, Lv Z, Meng X, Wang G, et al. Clinical characteristics and treatment outcomes of parathyroid carcinoma: A retrospective review of 234 cases. Oncol Lett [Internet]. 2017 Dec. [cited 2019 May. 8];14(6):7276-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29344163

https://doi.org/10.3892/ol.2017.7076

Quinn CE, Healy J, Lebastchi AH, Brown TC, Stein JE, Prasad ML, et al. Modern experience with aggressive parathyroid tumors in a high-volume new england referral center. J Am Coll Surg. 2015 Jun. 1;220(6):1054-62.

https://doi.org/10.1016/j.jamcollsurg.2014.10.007

Builes CA, Román A, Góez E, Giraldo DP, Múnera JD, Uribe F, et al. Hiperparatiroidismo clásico asociado a carcinoma papilar de tiroides: reporte de caso y revisión. Rev Med [Internet]. 2006 [citado 2019 en. 19];14(1). Available from: https://www.redalyc.org/articulo.oa?id=91014114

Santiago-Chinchilla A, Ramos-Font C, Muros de Fuentes MA, Navarro-Pelayo Láinez M, Palacios-Gerona H, Moreno-Caballero M, et al. False negative scintigraphy with 99mTc-sestamibi in parathyroid carcinoma with associated brown tumors. Contributions of 18F-FDG-PET/CT. Rev Española Med Nucl (English Ed [Internet]. 2011 Jan. 1 [cited 2019 Jan. 19];30(3):174-9. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1578200X11700249

https://doi.org/10.1016/S1578-200X(11)70024-9

Hyrcza MD, Sarg?n P, Mete O. Parathyroid Lipoadenoma: a Clinicopathological Diagnosis and Possible Trap for the Unaware Pathologist. Endocr Pathol [Internet]. 2016 Mar. 19 [cited 2019 Jan. 19];27(1):34-41. Available from: http://link.springer.com/10.1007/s12022-015-9404-5

https://doi.org/10.1007/s12022-015-9404-5

McCoy KL, Chen NH, Armstrong MJ, Howell GM, Stang MT, Yip L, et al. The small abnormal parathyroid gland is increasingly common and heralds operative complexity. World J Surg. 2014;38(6):1274-81.

https://doi.org/10.1007/s00268-014-2450-1

Storvall S, Ryhänen E, Bensch F V, Heiskanen I, Kytölä S, Ebeling T, et al. Recurrent Metastasized Parathyroid Carcinoma-Long-Term Remission After Combined Treatments With Surgery, Radiotherapy, Cinacalcet, Zoledronic Acid, and Temozolomide. JBMR Plus [Internet]. 2018; 1-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478586/pdf/JBM4-3-na.pdf

https://doi.org/10.1002/jbm4.10114

Wei-wei L, You-ben F, Qi Z, Xian-zhao D. Diagnosis and Treatment of Parathyroid Carcinoma?: Report of Seven Cases and Review of Literature. JSM Gen Surg Cases Images. 2018;3:1-5.

Wang P, Xue S, Wang S. Clinical characteristics and treatment outcomes of parathyroid carcinoma: A retrospective review of 234 cases. Oncol Lett. 2017; 14:7276-82.

https://doi.org/10.3892/ol.2017.7076

Munson ND, Foote RL, Northcutt RC, Tiegs RD, Fitzpatrick LA, Grant CS, et al. Parathyroid carcinoma: Is there a role for adjuvant radiation therapy? Cancer [Internet]. 2003 Dec. 1 [cited 2019 May. 8];98(11):2378-84. Available from: http://doi.wiley.com/10.1002/cncr.11819

https://doi.org/10.1002/cncr.11819

Rozhinskaya L, Pigarova E, Sabanova E, Mamedova E, Voronkova I, Krupinova J, et al. Diagnosis and treatment challenges of parathyroid carcinoma in a 27-year-old woman with multiple lung metastases. Endocrinol diabetes Metab case reports [Internet]. 2017 [cited 2019 May. 9];2017. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28458892

https://doi.org/10.1530/EDM-16-0113

Tsushima Y, Sun S, Via MA. Brown Tumors Secondary To Parathyroid Carcinoma Masquerading As Skeletal Metastases on 18 F-Fdg Pet/Ct -a Case Report . AACE Clin Case Reports. 2019.

https://doi.org/10.4158/ACCR-2018-0633

Salcuni AS, Cetani F, Guarnieri V, Nicastro V, Romagnoli E, de Martino D, et al. Parathyroid carcinoma. Best Practice and Research: Clinical Endocrinology and Metabolism. 2018.

https://doi.org/10.1016/j.beem.2018.11.002

Payne RB, Little AJ, Williams RB, Milner JR. Interpretation of serum calcium in patients with abnormal serum proteins. Br Med J [Internet]. 1973 Dec. 15 [cited 2019 Aug. 15];4(5893):643-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4758544

https://doi.org/10.1136/bmj.4.5893.643

Wynne AG, Van Heerden J, Carney JA, Fitzpatrick LA. Parathyroid carcinoma: clinical and pathologic features in 43 patients. Medicine (Baltimore) [Internet]. 1992 Jul. [cited 2019 Jan 26];71(4):197-205. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1518393

https://doi.org/10.1097/00005792-199207000-00002

Kim BS, Ryu HS, Kang KH, Park SJ. Parathyroid carcinoma in tertiary hyperparathyroidism. Asian J Surg [Internet]. 2016 Oct. 1 [cited 2019 Jan. 19]; 39(4):255-9. Available from: https://www.sciencedirect.com/science/article/pii/S1015958413000080

https://doi.org/10.1016/j.asjsur.2013.01.007

Presa Fernandes JM, Paiva C, Correia R, Polónia J, Moreira da Costa A. Parathyroid carcinoma: from a case report to a review of the literature. Int J Surg Case Rep [Internet]. 2018 Jan. 1 [cited 2019 Jan. 19];42:214-7. Available from: https://www.sciencedirect.com/science/article/pii/S2210261217306089

https://doi.org/10.1016/j.ijscr.2017.11.030

Mori H, Okada Y, Arao T, Tanaka Y. A case of parathyroid carcinoma with a highly aggressive clinical course. J UOEH [Internet]. 2014 Dec. 1 [cited 2019 Jan. 19];36(4):243-9. Available from: http://jlc.jst.go.jp/DN/JST.JSTAGE/juoeh/36.243?lang=en&from=CrossRef&type=abstract

https://doi.org/10.7888/juoeh.36.243

Kolsi N, Jellali S, Koubaa J. Parathyroid carcinoma: about a case and review of the literature. Pan Afr Med J [Internet]. 2017 [cited 2019 Jan. 22];27:85. Available from: http://www.panafrican-med-journal.com/content/article/27/85/full/

https://doi.org/10.11604/pamj.2017.27.85.11584

Banco de la República. Salarios | Banco de la República (Banco Central de Colombia) [Internet]. Salarios. 2015 [citado 2019 abr. 28]. Available from: http://www.banrep.gov.co/es/salarios

neoplasias de las paratiroides
fracturas óseas
osteoporosis posmenopáusica
fracturas de cadera
nódulo tiroideo
hiperparatiroidismo primario