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case_images: Histoscans (A) - parathyroid hyperplasia, material after surgery in 2013; (B-F) - PC, material after surgery in 2023. (A) Diffuse parathyroid hyperplasia (H&E); (B) Oxyphilic cells with areas of necrosis, fresh and old hemorrhages, tumor surrounded by a capsule with areas of invasive growth and vascular protrusions (H&E); (C) Diffuse expression of PTH in the tumor, negative in the surrounding tissue; (D) CD31 - absence of vascular invasion signs; (E) Ki-67 3%; (F) Loss-of-expression of parafibromin.
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case_images: Histological examination confirmed diffuse parathyroid hyperplasia ( Figure 1A ), immunohistochemistry was not performed. The consistent histopathological and immunohistochemical findings confirmed multifocal PC pT2NxMx ( Figures 1B-F ).
case_images: Physical examination of patient M. on admission. (A, B) Craniofacial anomalies affecting the maxilla and mandible, malocclusions, and dental irregularities. (C) Distal phalangeal deformities.
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case_images: The physical examination revealed severe distal phalangeal deformities, altered posture, and a restricted range of motion in the hips and knees, as shown in  Figure 2 .
case_images: X-ray of the thoracic spine in lateral projection and the skull in frontal and lateral projections. (A) Th6-8,12 compression fractures. (B, C) Subcortical resorption on the alveolar masticatory surface (arrow) and multiple bone cysts in maxilla/mandible between 2 and 10.6 mm in the maxilla/mandible, multiple foci of fibrosis and endosellar calcification of the dura mater.
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case_images: Th6-8,12 (28-58% vertebral body height loss) and initial decrease in vertebral height at Th9-10, L1-5 (10-18%) as shown in  Figure 3A . These findings suggested negative progression compared to the 2016 assessment. Skull radiographs demonstrated pathological features typical for SS ( Figures 3B, C ).