Case Of Ectopic Parathyroid Adenoma Research Articles

SAT200 A Case Of Ectopic Parathyroid Adenoma With Significantly Improved Renal Function And Insulin Resistance After Parathyroidectomy

Abstract Disclosure: S. Lee: None. H. Ppyun: None. Y. Shin: None. N. Hong: None. H. Choi: None. Background: It is challenging to treat patients with clinically suspected hyperparathyroidism not localized by conventional imaging methods. Here, we present clinical evidence that supports new modalities for localization and ultimate surgical removal of a lesion. Clinical case: An increase in calcium and PTH was found incidentally in a 59 YO male patient who was followed up for type 2 diabetes mellitus and DMCKD (stage 4). Initial lab tests were as follows: Ca, 11.6 mg/dL (8.2∼10.8); P 3.3 mg/dL (2.5∼4.7); PTH 184.1 pg/mL (18.5∼88.0); BUN/Cr 4.84/3.38 mg/dL (8∼22/0.5∼1.2); protein in random urine 1020.1 mg/dL (6∼20). Suspected of primary hyperparathyroidism, ultrasonography and sestamibi scan were performed, but no parathyroid lesions were found. While only palliative treatment was maintained, parathyroid venous sampling (PVS) (1) and 18-fluorocholine PET/CT (2) were performed, and a mass within 2 cm in diameter was found in the left mediastinum, which was then removed by thoracoscopic robotic excision. Diffuse weak staining for PTH in the removed lesion confirmed that it was a tissue derived from the parathyroid gland. After surgery, lab tests were improved as follows: Ca 9.1 mg/dL; P 3.6 mg/dL; PTH 69 pg/mL. When 90 units of insulin were administered before surgery, HbA1c was 8.7%, but even after insulin was reduced to 15 units post-surgery HbA1c decreased to 7.2%, significantly reducing the need for insulin treatment. Proteinuria also decreased to 123.1 mg/dL, indicating that renal function was also improved. Conclusion: This case highlights the merit of newly introduced 18-fluorocholine PET/CT and PVS to find a parathyroid lesion that could not be found by conventional imaging methods. It is recommended to consider active surgical treatment for hyperparathyroidism, mainly to prevent deterioration of bone health and kidney function. In addition, since concurrent diabetes can be improved by parathyroidectomy (3), this case shows the need to more actively find lesions and take a causal approach. Reference: (1) Yamada T, Ikuno M, Shinjo Y, Hiroishi A, Matsushita S, Morimoto T, et al. Selective venous sampling for primary hyperparathyroidism: how to perform an examination and interpret the results with reference to thyroid vein anatomy. Jpn. J. Radiol. 2017;35:409-16. (2) Marina Orevi 1, Nanette Freedman, Eyal Mishani, Moshe Bocher, Orit Jacobson, Yodphat Krausz. Localization of parathyroid adenoma by ¹¹C-choline PET/CT: preliminary results. Clin. Nucl. Med. 2014;39:1033-8 (3) Noghani SN, Milani N, Afkhamizadeh M, Kabiri M, Bonakdaran S, Vazifeh-Mostaan L, et al. Assessment of insulin resistance in patients with primary hyperparathyroidism before and after Parathyroidectomy. Endocrinol Diab Metab. 2021;4:e00294. Presentation: Saturday, June 17, 2023

Abstract #1373163: A Rare Case of Ectopic Parathyroid Adenoma in the Left Axillary Region

A parathyroid adenoma is a benign neoplasm that arises from parathyroid parenchymal cells. Parathyroid adenomas are the most common cause of primary hyperparathyroidism (PHPT). Ectopic parathyroid adenomas arise within the parathyroid glands located at the four poles of the thyroid [2]. Ectopic parathyroid adenomas result from aberrant migration of the gland during the early stages of development and can be identified in up to 16% of cases of PHPT [3]. They are commonly found in the mediastinum, within the thyroid, and along the path of the vagus or recurrent laryngeal nerves [4]. 45% of ectopic parathyroid adenomas are found in the paraesophageal region, 25% in the cervical thymus, 20% in the cervical mediastinum, 5% in the anterior portion of the mediastinum, and 5% at the level of the thymus [5]. A 64-year-old man with a past medical history of over 20-year history of recurrent nephrolithiasis, type II diabetes mellitus, dyslipidemia, hypertension, and pancreatic cancer presented to our outpatient endocrine clinic for evaluation of hyperparathyroidism. Further investigation of his history revealed that he had struggled with several bouts of urinary calculi throughout his life. These episodes required multiple surgical interventions to treat, including left nephrectomy and ureteral stenting. He had been evaluated for high serum calcium in the past and was diagnosed with PHPT by his urologist, who referred him to our clinic. Also complicating his health was a recent diagnosis of prostate cancer for which, he was undergoing radiation treatment. He had a family history of thyroid disorder in his mother but no family history of parathyroid disorders. Physical examination was unremarkable. Laboratory investigations revealed high serum calcium and high serum parathyroid hormone. Parathyroid scintigraphy with 99mTc-sestamibi revealed a subtle persistent focal region of increased uptake in the left axilla with no other areas of increased uptake, raising the suspicion for parathyroid adenoma in the left axilla. As discussed earlier, ectopic parathyroid adenomas result from aberrant migration of parathyroid tissue during embryological development. Additionally, ectopic parathyroid adenomas are a cause of failed surgery for hyperparathyroidism as well as persistent and recurrent hyperparathyroidism [3, 7-9]. Ectopic parathyroid tissue has a prevalence of 2-43% in anatomic series and has been detected in up to 16% of patients undergoing evaluation for hyperparathyroidism [3, 7, 10]. Ectopic parathyroid adenomas arising within the axilla may present with hypercalcemia and associated skeletal and renal involvement [11, 12]. The case that has been reported had a presentation of PHPT with recurrent nephrolithiasis. As mentioned earlier, 45% of ectopic parathyroid lesions are found in the paraesophageal region with 38% arising within the thymus [7, 10]. However, in this case, the patient presented with a possible ectopic parathyroid adenoma localized to the left axilla and no other areas of increased uptake on tc99m-sestamibi parathyroid scintigraphy.

Ectopic Mediastinal Parathyroid Adenoma Excision via Video Assisted Thoracoscopic Approach: A Case Report

Ectopic parathyroid adenomas can be a cause of recurrent and refractory hyperparathyroidism. Majority of parathyroid adenomas are located in the neck region, however in very few cases they are located within the mediastinum. In such cases excision via cervical approach is not possible and it becomes a diagnostic as well as surgical challenge. Excision via thoracoscopic approach is a preferred approach in this regard. Here we represent a case of ectopic parathyroid adenoma embedded within thymus gland which underwent surgical excision via thoracoscopic approach.
 Key words: Ectopic, Parathyroid adenoma, Thoracoscopy

Clinicopathological Analysis of Anterior-Superior Mediastinal Masses

Background: The mediastinum is the space between the two lungs, bounded anteriorly by the sternum and posteriorly by the vertebral column. A spectrum of neoplastic and non-neoplastic lesions can arise in the mediastinum.
 Methods: A total of 14 cases were retrospectively retrieved from the Histopathology department. The cases had histopathological diagnosis either in image guided, thorocoscopic, transbronchial or excision biopsies.
 Results: The majority of cases (43% n=6) were of thymic origin, which included both neoplastic lesions of thymoma group and non-neoplastic lesion like thymic cysts. The thymoma group included 3 cases of thymoma B3 and 1 case of thymoma AB. The lymphoid lesions include Hodgkin lymphoma (14.3%; n=2) and non-Hodgkin lymphoma (7.1%; n=1). The mesenchymal lesions (21.4%; n=3) included lipoma, solitary fibrous tumor and schwannoma which accounts for one case each. A rare case of ectopic parathyroid adenoma (7.1%; n=1). and a case of metastatic papillary carcinoma (7.1%; n=1) were also reported.
 Conclusion: The diagnosis of mediastinal mass lesions can pose difficulties due to its wide clinicopathologic spectrum to the clinician, radiologists and pathologist. A multimodal approach with histopathological examination and immunohistochemistry can help in arriving at an accurate diagnosis.

RARE AND DEMANDING: PARATHYROID ADENOMA LOCALIZATION, SURGERY AND OUTCOME.

Objectives: To assess the methods of preoperative parathyroid adenoma localization and to compare it with operative findings. Patients and methods: Between June 2017 and June 2019, we had operated 8 cases of parathyroid adenomas. Three patients were males and 5 patients were females. Age ranged from 26 year old to 72 year old with average of 42 year old. Seven cases were sporadic while one case was part of MEN2a. All patients had ultrasonography for preoperative localization, all had CT scan and 4 patients had Sestamibi scan. In all patients, intraoperative measurements of parathyroid hormone was done before and 10 minutes after surgical excision. Results: Ultrasonography was successful in localizing only one case with certainty. CT scan located the adenoma in another 2 patients. In 4 patients who performed Sestamibi scan, the adenomas were located precisely in all of them including one case of ectopic parathyroid adenoma behind the sternum. In one patient, all the modalities failed in localization which was achieved easily intraoperatively. Single adenoma was found in 6 patients and two adenomas in two patients. The adenomas were located in the neck in 7 patients and in the anterior mediastinum in one patient .Surgical removal was done through neck incision in 7 cases while midline sternotomy in one case. All the patients had resolution of symptoms within the follow up period. Conclusion: Sestamibi scan is the best investigation in preoperative localization of parathyroid adenoma. Ultrasonography and CT scan can aid in the diagnosis with less sensitivity. Intraoperative localization is possible even in cases of negative investigations.

Intérêt de l’imagerie scintigraphique, à Madagascar, dans le diagnostic de l’adénome parathyroïdien ectopique – à propos d’un cas

This study reports the first case of ectopic parathyroid adenoma, diagnosed in the Department of Nuclear Medicine in Antananarivo. This clinical vignette illustrates the interest of the MIBI-Tc-99 m scan in locating this adenoma and its diagnostic confirmation after six years of erratic diagnosis. A whole body bone scintigraphy has also allowed to assess the state of bone metabolism and study outbreaks of fracture. The parathyroid scintigraphy was carried out after intra-venous administration of 666 MBq of MIBI-Tc99m. Dynamic images, static early and late static were acquired with a gamma camera E-Cam Siemens. The whole body bone scan was carried out after administration of 555 MBq of MDP-Tc-99 m. The results evidenced the presence of an para-aortic increased uptake area pointing to a left parathyroid adenoma. The persistence of a late left submaxillary increased uptake area raises, however, a reservation about the existence of a second adenoma. The bone scan displayed global skeletal remodeling, non suggestive of metastases, as it was mentioned with the CT-scan. In a diagnostic tools limited environment, skeletal pain refractory to painkillers, a chronic hypercalcemia associated with an increased parathyroid hormone level, should trigger the scintigarphic exploration in order to avoid bone and renal complications.

Diagnosis of a Case of Ectopic Parathyroid Adenoma on the Early Image of 99mTc-MIBI Scintigram

We report the case of a 64-year-old woman who had a severe hypercalcemia. Serum calcium, intact parathyroid hormone (PTH), 1alpha, 25 (OH)(2 )vitamin D(3) levels were all elevated, and serum phosphorus level was decreased, which were all consistent with primary hyperparathyroidism (PHPT). (201)Tl/(99m)Tc subtraction scintigraphy failed to detect any abnormal accumulation in the neck and chest, while (99m)Tc-MIBI scintigraphy demonstrated the focal accumulation of increased radiotracer uptake in the mediastinum only on the early image, but not on the delayed image. Neck and chest computerized tomography scanning showed a small nodule at the retrosternal region, and a selective venous sampling study of the intact PTH suggested PTH production from the nodule. Together with the observation of the early image of (99m)Tc-MIBI scintigraphy, it was diagnosed that the patient had an ectopic parathyroid adenoma. Video-assisted thoracic surgery was performed. A 15-mm diameter mass, visualized by an intravenous infusion of methylene blue, was excited. The histopathology was consistent with the parathyroid adenoma. The adenoma was composed of mainly chief cells and rarely oxyphil cells. The absence of oxyphil cells would explain the lack of (99m)Tc-MIBI retention on late-phase imaging in our case. Even without uptake on the delayed image of (99m)Tc-MIBI scintigram, the early image was available for the localization of an ectopic parathyroid adenoma.

Summary Parathyroid Adenoma in the Upper Mediastinum

We report a case of ectopic parathyroid adenoma in the upper mediastinum. A 51-year-old Japanese woman presented hypercalcemia and repeated pancreatitis. The serum parathyroid hormone level was high and Tc-99m methoxyibutylisonitrile scintigraphy showed an abnormal hot-spot in the left side of the upper mediastinum. Therefore, an ectopic parathyroid adenoma was diagnosed. A dark red tumor of 18 mm in diameter located in the thymus was resected under general anesthesia. Postoperative condition was good, with the levels of serum calcium and parathyroid hormone maintained within normal limits. This case indicates that Tc-99m MIBI scintigraphy is highly recommended for detecting parathyroid tumor in an ectopic area.