American Journal of Medical Case Reports, 2014, Vol. 2, No. 10, 225-226 Available online at http://pubs.sciepub.com/ajmcr/2/10/7 © Science and Education Publishing DOI:10.12691/ajmcr-2-10-7 Simultaneous Presentation of Metastatic Cancer and Primary Hyperparathyroidism – A Case Series Hiang Leng Tan 1,* , Muhammad Imran Butt 2 , Najeeb Waheed 3 1 Department of Diabetes and Endocrinology, Weston General Hospital, Weston-super-Mare, UK 2 Department of Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, UK 3 Department of Diabetes and Endocrinology, Hereford County Hospital, Hereford, UK *Corresponding author: hiangleng@doctors.org.uk Received October 05, 2014; Revised October 20, 2014; Accepted October 23, 2014 Abstract The objective of our two case reports is to increase awareness of the simultaneous occurrence of primary hyperparathyroidism and malignancy in patients that presents with hypercalcaemia. This report reviews the case reports from the history, investigation, treatment and outcome for these two patients. A literature review of the association between malignancy and primary hyperparathyroidism was also performed. Both patients had metastatic cancer and primary hyperparathyroidism but died within months of diagnosis despite treatment for their primary malignancy. This serves as a reminder that these two separate diagnoses do exist, though it did not alter the outcome of our patients. However, we propose that in patients with malignancy who presents with hypercalcaemia and non- suppressed PTH level, further workup should be instigated to rule out primary hyperparathyroidism as surgical option is potentially curative for the latter. Keywords: primary hyperparathyroidism, metastatic cancer, hypercalcaemia Cite This Article: Hiang Leng Tan, Muhammad Imran Butt, and Najeeb Waheed, “Simultaneous Presentation of Metastatic Cancer and Primary Hyperparathyroidism – A Case Series.” American Journal of Medical Case Reports, vol. 2, no. 10 (2014): 225-226. doi: 10.12691/ajmcr-2-10-7. 1. Introduction Primary hyperparathyroidism is a common endocrine disorder. Its prevalence has been estimated at 3 in 1000 in the general population and as high as 21 in 1000 in postmenopausal women. [1] 85% of patients with primary hyperparathyroidism are due to a single parathyroid adenoma, 14% due to parathyroid hyperplasia and less than 1% due to carcinoma. Although primary hyperparathyroidism is considered a benign condition, it has been linked with various malignancies. Dent and Watson [2] reported the first case where a patient presented with both primary carcinoma of the cervix and primary hyperparathyroidism due to parathyroid adenoma. Subsequently Palmer et al [3] reported an excess risk of malignancy in over 4000 patients in the Swedish Cancer Registry (1960-1981) who had undergone surgery for primary hyperparathyroidism. Using the same data from the Swedish Cancer Registry (1958-1997), Michels et al [4] found an observed association between hyperparathyroidism and subsequent breast cancer, although mechanism of its association remains unclear. We report two cases where both patients presented with simultaneous diagnosis of primary hyperparathyroidism and metastatic cancer. The first case demonstrates the already known association with breast cancer with the second case involving oesophageal malignancy which has not been reported. However, in both of the cases, a cause of their primary hyperparathyroidism was not identified as they were too unwell for further radiological imaging to identify the presence of the parathyroid adenoma and they eventually died from their primary malignancy. 2. Case 1 A 53 year old woman, with a history of right sided breast cancer presented as an emergency due to general deterioration and was found to have hypercalcaemia. She had undergone mastectomy, completed six cycles of chemotherapy and 25 fraction of radiotherapy ten months prior to admission. Blood test revealed an adjusted calcium of 5.54nmol/L (NR 2.10-2.55nmol/L), PTH related peptide (PTHrp) of > 60pmol/L (NR 0.0-1.8pmol/L), unsuppressed PTH 34 ng/L (15-65 ng/L) and Vitamin D of 78nmol/L ( NR 50-200). Further investigation included bone scan which did not show bony metastasis and an abdominal ultrasound revealing liver metastasis. Her calcium level had improved with intravenous fluids and bisphosphonate therapy, but had remained elevated at 3.67nmol/L. However, she had continued to deteriorate clinically and died during this admission. 3. Case 2 A 52 year old lady was admitted to the hospital with a two week history of right scapula pain, reduced appetite