SESSION TITLE: Miscellaneous Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Approximately 85 percent of primary hyperparathroidism (PHPT) is usually caused by solitary parathyroid adenomas. In 5-10% of cases derived from ectopic adenomas. The ectopic tissue can occur anywhere from pericardium to nasal septum; but it usually occurs in thymus which develops from the same embryologic tissue (3. pharyngeal poshe). It can also occur in thyroid, carotid sheath, retroesophagus area, mediastinum, servical muscles, hypopharings, sublingual or aorta-pulmonary areas. Mediastinal localisation is less than %5 of ectopic parathyroid localisations. (1).
CASE PRESENTATION: Sixty-four year old female patient admitted to neprology unit complaining with weakness, fatigue, nausea, polidypsia, polyuria and stomachache. The patient’s history had subtotal thyrodectomy nearly ten years ago due to multinodulary goiter. In the physical examination, there was no pathological finding. In the biochemical analysis, serum calcium (Ca) was 12 mg/dl (normal range : 8.4-10.2 mg/dl) and phosphorus levels was 2.1 mg/dl(normal range:2.7-4.5mg/dl ), 24 hour urine Ca level was 668 mg/d(normal range:100-320 mg/d) and parathormone (PTH) level was 113 pg/ml(normal range:7-53 pg/ml), as indicated with PHPT. Thyroid ultrasonography showed multiple nodules with sizes ranged from 16 to 28 mm. Considering surgical criteria; bone mineral densitometry (DEXA) showed osteoporosis (lumbar T score -3.1). Parathyroid scintigraphy showed that irregular activity of right inferior thyroid which is thought to be a residue thyroid tissue or parathyroid adenoma. Thorax computerized tomography (CT) showed a vertical, 40x15mm in sized, tubular soft tissue, localised right upper paratracheal area, near the oesophagus, which is thought to be lenf node or ectopic thyroid tissue. Surgery was planned, and total thyroidectomy was performed; all parathyroid glands were examined and were found to be normal, suspected parathyroid tissues were removed. After the surgery, there was no improvement both clinically and laboratory; second parathyroid scintigraphy and SPECT were performed. SPECT investigation showed an activity owning to inferior region and no thyroid activity. Activity accumulation was continued in late images. SPECT and previous CT images were re-evaluated, upper paratracheal region, near the oesophagus, a 25x18x39 mm in diameter mass was considered as an ectopic parathyroid. Second surgery was planned by chest surgeons, right posterolateral thorachothomy was performed with gamma-probe, the mass was observed on the trachea and then the mass was removed (Figure). After the surgery, hypothyroidism and hypoparathyroidism were developed, and L-thyroxine, calcium and vitamin D replacement therapy were started.
DISCUSSION: The most effective image technique to determine the ectopic parathyroid adenoma is Tc 99m MIBI scintigraphy, even though US; MR and CT can be used (2). In our case, first MIBI scintigraphy couldn’t locate ectopic adenoma. After performing SPECT, the mass was observed as upper mediastinal mass. Upper mediastinal parathyroid adenomas especially anterior mediastinal thymic lesions resectable by partial or total sternothomy with or without manubrotomy (3). Even though nodule sizes less than 2 cm may not be visualised by the MIBI. SPECT investigation must be performed in all patients whose adenomas could not be visualized by the MIBI.
CONCLUSIONS: Intraoperative gamma probe technique can expedite to find the lesions. Video assisted thoracoscopic surgery (VATS) is another alternative method for anterior and posterior mediastinal lesions. VATS is more effective, comfortable with less postsurgery pain. Recently, it could be possible to make alcohol ablation therapy, sclerosane injection by angiography and talk about effectiveness.
Reference #1: Jaskowiak N,Norton JA,Alexander HR,et al. A prospective trial evaluatinga standart approach to reoperation for missed parathyroid adenoma Ann Surg 1996;224:308-22
Reference #2: Caravalho J,Balingit AG,Rivera-Rodriguez JE,et al. Localization of an parathyroid adenoma by double-phase technetium-99m-sestamibi scintigraphy.J Nucl Med 1995;36:1840-2
Reference #3: Murat Kara, Adem Güngör. A case of primary hyperparathyroidism secondary to ectopic parathyroid adenoma located in thymus. Tuberk Toraks 2001;49:497-9
DISCLOSURE: The following authors have nothing to disclose: Orkide Kutlu, Mustafa Calik, Cevdet Duran, Hidir Esme, Omer Karahan, Taha Bekci
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