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A 47-yr-old man, diagnosed with parathyroid carcinoma in 1989 (1), was noted on routine follow-up 18 yr later to have raised adjusted calcium (2.82 mmol/liter) and PTH (29.9 pmol/liter; normal range, 1.3–6.8 pmol/liter) after previously normal values. Serum calcium continued to increase despite treatment with a calcimimetic (Cinacalcet) at a dose of 60 mg twice daily for 1 month, and the patient required iv pamidronate to reduce his calcium level. The patient was otherwise well, with normal clinical examination and neck ultrasound. Thoracic computed tomography (CT) demonstrated a 1 × 1.5-cm nodule in the right lung of unknown significance, not amenable to percutaneous biopsy. Technetium 99m-sestamibi examination and indium-labeled octreotide whole body and single photon emission CT of the mediastinum were normal (Fig. 1). Subsequently, an 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) CT was performed, which showed increased 18F-FDG activity with a maximum standardized uptake value (SUV max) of 3.2 in the lung nodule. The nodule was removed by open thoracotomy with immediate and sustained normalization of the serum calcium (postoperative PTH, 6.1 pmol/liter; adjusted calcium, 2.04 mmol/liter). Calcium remains normal 12 months after surgery. Histology demonstrated metastatic parathyroid carcinoma.

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