Abstract
Rarely, patients with recurrent hyperparathyroidism have mediastinal parathyroid adenomas. These lesions often difficult to diagnose, requiring multiple sophisticated localization techniques. We describe our experience with diagnosing two patients with mediastinal parathyroid adenomas using EUS-guided FNA cytology combined with parathormone assay on the aspirate sample. Case 1: A 54-year-old white male had a persistently elevated serum calcium and PTH level despite removal of a right inferior parathyroid adenoma. Sestamibi CT subsequently revealed a mass superior to the azygous vein. Radial EUS confirmed the presence of 3 cm solid/cystic lesion which on subsequent EUS-FNA showed epithelioid proliferation consistent but not diagnostic of a parathyroid adenoma. However, PTH assay performed on an aspirate sample diluted in 3 ml of saline was positive at 1800 pg/mL. Pathology of the resected specimen revealed a 29.7 g parathyroid adenoma. Case 2: An 86-year-old African-American female had recurrent hyperparathyroidism following removal of a left superior parathyroid adenoma. Chest CT scan revealed enhancing nodule within the right superior mediastinum. EUS-FNA showed a 0.6 × 2.0 cm right paraesophageal lesion which cytologically showed scant epitheliod cell groups. PTH assay on the diluted aspirate was diagnostic at 6905 pg/mL. She is being managed medical at present. Discussion: Preoperative localization of recurrent or persistent hyperparathyroidism is often a difficult clinical problem. Transcutaneous ultrasonography (TUS), CT, MRI, thalium-technetium, and sestamibi scans have all be used with predictive values ranging from 40 to 80%. First described by Doppman in 1983, TUS of suspicious neck lesions with concomitant PTH assay of the aspirate has become increasingly useful with sensitivities between 70–100% and a specificity of 100%. Using EUS-FNA with PTH assay on the aspirate in suspected mediastinal parathyroid adenomas is a logical extension of this technique. To our knowledge, these cases represent the first reported examples of this technique. We suggest that this procedure may be useful in definitively diagnosing patients with suspected mediastinal parathyroid adenomas.
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