Volume 140, Issue 6, Pages 1654-1658 (December 2011) A 32-Year-Old Man With Recurrent Kidney Stones and an Abnormal Chest Radiograph  Fayez Kheir, MD, Francesco Simeone, MD, Sean Johnston, MD, Rodney Shackelford, DO, Joseph Lasky, MD, FCCP  CHEST  Volume 140, Issue 6, Pages 1654-1658 (December 2011) DOI: 10.1378/chest.10-3268 Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 1 Chest radiographs showing multifocal expansile lytic bony lesions involving the ribs, humeri, scapulae, and clavicles; reabsorption of the lateral clavicles; and mid-right- and mid-left-side lung zone opacities suggesting pleural-based masses. A, Posterior to anterior view. B, Lateral view. CHEST 2011 140, 1654-1658DOI: (10.1378/chest.10-3268) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 2 CT scan of the chest showing many expansile lytic lesions of the ribs with no intraparenchymal masses or nodules. A, Lung window. B, Mediastinal window. CHEST 2011 140, 1654-1658DOI: (10.1378/chest.10-3268) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 3 Biopsy specimen of the iliac bone showing mononuclear cells with round to oval nuclei and sarcomatoid features consisting of numerous spindle cells in a hypercellular, storiform configuration, which is a harbinger for more-destructive tumor behavior, along with scattered multinucleated giant cells with nuclei similar to those seen in the mononuclear cells. Abundant hemosiderin deposits indicate relatively recent hemorrhage. The lesion has replaced the bone marrow and surrounds normal-appearing trabecular bone. A, Hematoxylin-eosin, original magnification ×20. B, Hematoxylin-eosin, original magnification ×40. CHEST 2011 140, 1654-1658DOI: (10.1378/chest.10-3268) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 4 Ultrasonograph of the neck showing a heterogeneous cystic mass compatible with parathyroid adenoma. CHEST 2011 140, 1654-1658DOI: (10.1378/chest.10-3268) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 5 Sestamibi scan showing increased radiotracer uptake in the right lower neck. CHEST 2011 140, 1654-1658DOI: (10.1378/chest.10-3268) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 6 Biopsy specimen of the parathyroid gland showing abundant granular eosinophilic cytoplasm with mild to moderate cellular pleomorphism. Both capsular invasion and invasion into the thyroidal parenchyma are identified, indicating that the lesion is a parathyroid carcinoma. A, Hematoxylin-eosin, original magnification ×20. B, Hematoxylin-eosin, original magnification ×40. CHEST 2011 140, 1654-1658DOI: (10.1378/chest.10-3268) Copyright © 2011 The American College of Chest Physicians Terms and Conditions