PMC9927209_01
Thyroid ultrasonography, 99m Tc-MIBG, pelvic MRI, and PET-CT of a 56-year-old woman with life-threatening hypercalcemia. Thyroid ultrasonography (A) and 99m Tc-MIBG (B) showed a nodule inferior the left thyroid lobe, which may origin from parathyroid. Pelvic MRI (C) showed the uterus enlarged, with disrupted junctional zone, thickened myometrium, and abnormal signals in the uterine cavity. PET-CT (D) showed the irregularly enlarged uterus with increased SUV value (max to 15.7), as while multiple enlarged lymph nodes along the uterus, abdominal aorta, and bilateral common iliac arteries (SUVmax 15.5).
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Pelvic MRI imaging showed an enlarged uterus with disrupted junctional zone, thickened myometrium, and abnormal signals in the uterine cavity ( Figure 1C ). PET-CT showed increased SUVmax of 15.7 in an irregularly enlarged uterine ( Figure 1D ) and multiple lymph nodes along the uterus, abdominal aorta, and bilateral common iliac arteries (SUVmax 15.5).
Serum calcium and parathyroid hormone (PTH) levels during patient's hospitalization. Reference range of serum calcium: 8.52-10.80mg/dl, reference range of PTH: 12-69pg/ml.
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The level of serum calcium and PTH dropped immediately to normal range after surgery (calcium: 9.6mg/dl, reference range: 8.52-10.80mg/dl; PTH: 60pg/ml, reference range: 12-69pg/ml) ( Figure 2 ). In accordance with the curettage specimen, the carcinoma cells stained positive for PTH ( Figure 2E ), as while diffusely positive for AE1/AE3 ( Figure 3F ), MSH2 and MSH-6, focally positive for CK7, CK5/6 and CK34betae, and negative for Vimentin, S-100, LCA, MPO, SALL-4, Calcitonin, MLH-1 ( Figure 3G ) and PMS-2 ( Figure 3H ).
Gross photograph and pathological characteristics of the tumor. (A) showed the enlarged uterus. The endometrium was irregularly demolished, and the uterine wall and serous membrane were invaded. (B) showed the poorly differentiated carcinoma cells invaded the whole uterine wall with multiple embolisms. (C) indicated the poorly differentiated carcinoma with focal glandular formation (arrow). (D) showed focal squamous differentiation (arrow). (E) showed focal PTH staining. (F) showed diffusely AE1/AE3 staining. The tumor cells showed MLH-1 (G) and PMS-2 (H) negative staining contrast to the mesenchymal cells.
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The excised specimen grossly showed the uterus enlarged to 15.1x13.2x7.3cm ( Figure 3A ). Histologically, the carcinoma was high grade, and focally showed both glandular and squamous differentiation ( Figures 3B-D ). In accordance with the curettage specimen, the carcinoma cells stained positive for PTH ( Figure 2E ), as while diffusely positive for AE1/AE3 ( Figure 3F ), MSH2 and MSH-6, focally positive for CK7, CK5/6 and CK34betae, and negative for Vimentin, S-100, LCA, MPO, SALL-4, Calcitonin, MLH-1 ( Figure 3G ) and PMS-2 ( Figure 3H ). The final diagnosis was high grade MMR-deficient endometrioid carcinoma ( Figure 3 ).