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Year : 2019  |  Volume : 34  |  Issue : 2  |  Page : 164-166  

Single photon emission computed tomography/computed tomography detects a second ignored intrathyroidal parathyroid adenoma


1 Department of Otorhinolaryngology, Head and Neck, Clínica de Marly; Department of Otorhinolaryngology, Universidad Nacional de Colombia; Department of Head and Neck, Instituto Nacional de Cancerología, Bogota, Colombia
2 Department of Pathology, Clínica de Marly, Bogota, Colombia
3 Department of Nuclear Medicine, Clínica de Marly; Department of Nuclear Medicine, Hospital Militar Central, Bogota, Colombia

Date of Web Publication8-Apr-2019

Correspondence Address:
Dr. Enrique Cadena-Pineros
Cl. 50 # 9 – 67, Clínica de Marly, Bogota
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_22_19

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   Abstract 


The primary hyperparathyroidism (PHPT) is a result of high levels of parathyroid hormone and serum calcium, the most frequent cause is a solitary parathyroid adenoma. Double parathyroid adenoma is <5% of the PHPT. Intrathyroidal parathyroid adenoma (IPA) occurs<3.2%. We present a case of 58-year-old female with persistent primary hyperparathyroidism due to a second undetected IPA, suspected by ultrasound and confirmed by 99mTc sestamibi single-photon emission computed tomography/computed tomography.

Keywords: Hypercalcemia, hyperparathyroidism, parathyroidectomy, reoperation, single-photon emission computed tomography-computed tomography


How to cite this article:
Cadena-Pineros E, Romero-Rojas A, Romero D. Single photon emission computed tomography/computed tomography detects a second ignored intrathyroidal parathyroid adenoma. Indian J Nucl Med 2019;34:164-6

How to cite this URL:
Cadena-Pineros E, Romero-Rojas A, Romero D. Single photon emission computed tomography/computed tomography detects a second ignored intrathyroidal parathyroid adenoma. Indian J Nucl Med [serial online] 2019 [cited 2019 Jun 16];34:164-6. Available from: http://www.ijnm.in/text.asp?2019/34/2/164/255613



A 58-year-old female initially required resection of inferior right parathyroid; its histopathology reported a parathyroid adenoma of 1.5 cm × 0.8 cm. At 3 monthsPostoperative control, presented decrease of calcium from 11 mg/dL to 10.46 mg/dL (RV: 8.8–10.2), and reduction of intact parathyroid hormone (iPTH) from 159 pg/mL to 112 pg/mL (RV: 16–87). The patient had no follow-up for 10 years and did not complain of any symptoms related to hyperparathyroidism. After that, she consults for serum calcium of 11 mg/dL (RV: 8.8–10.2), iPTH of 159 pg/mL (RV: 16–87) and left inferior thyroid nodule compatible with follicular neoplasia, which was diagnostic by neck ultrasonography and fine-needle aspiration biopsy (FNAB). The 99m Tc sestamibi SPECT (single-photon emission computed tomography) parathyroid scintigraphy revealed a possible left inferior parathyroid adenoma [Figure 1]a, [Figure 1]b, [Figure 1]c.
Figure 1: (a-c) 99mTc sestamibi single-photon emission computed tomography/computed tomography parathyroid scintigraphy showed a left inferior parathyroid adenoma

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Suspecting an intrathyroidal parathyroid adenoma (IPA), it was decided to perform a 99m Tc sestamibi single-photon emission computed tomography/computed tomography (SPECT/CT), which confirmed an inferior left intrathyroid adenoma [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f.
Figure 2: (a-f) 99mTc sestamibi single-photon emission computed tomography/computed tomography confirmed an intrathyroid parathyroid adenoma

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Therefore, according to the findings of the ultrasonography [Figure 3]a, the patient underwent left hemithyroidectomy. Histopathology revealed an intrathyroidal parathyroid adenoma of 1,2x1,1 cm [Figure 3]b, [Figure 3]c, [Figure 3]d. The 99m Tc sestamibi parathyroid scintigraphy previous first surgery showed unclear uptake of the left inferior parathyroid gland [Figure 4]a, [Figure 4]b. Two years postoperative last surgery, serum calcium was 9.66 mg/dL (RV: 8.8–10.2), ionized calcium was 1.0 mmol/L (RV: 1.12–1.37), and iPTH had a normal level of 50.70 pg/mL (RV: 15–65).
Figure 3: (a) Neck ultrasonography reported an intrathyroid nodule (white arrows), (b) (H and E, panoramic view) Final histopathology confirmed an intrathyroidal parathyroid adenoma, (c) (H and E, panoramic view) Capsule thyroid sectioned. (d) Surgical specimen sectioned, revealed intrathyroid nodular lesion of 1.2 cm × 1.1 cm (black arrows). Thyr: thyroid

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Figure 4: (a) (H and E 10x) Intrathyroidal parathyroid adenoma: encapsulated neoplasms that are composed of chief cell, (b) The 99mTc sestamibi parathyroid scintigraphy previous first surgery, showed unclear uptake of the left inferior parathyroid gland (planar image)

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In 89% of cases, primary hyperparathyroidism is due to single-gland disease and 9.84% is a multiglandular disease. From this last group, 5.74% is for hyperplasia and 4.14% is for double adenomas.[1] The incidence of IPA is 1.4%–3.2%.[2] For these cases, neck ultrasonography sensitivity and scintigraphy sensitivity are <50%, showing only the second gland in a quarter of cases of double adenoma.[1] In our patient, an inferior right parathyroid adenoma was identified in the first surgery, but the left adenoma was not observed because it was hidden within the inferior pole of the thyroid.99m Tc sestamibi SPECT/CT provides an exact anatomical location of the abnormal glands, especially when they are ectopic.[3],[4] García-Talavera et al. demonstrated that the SPECT/CT has better sensitivity compared with planar imaging (90% vs. 72.5%).[3] We were able to confirm this assertion, once images of 99m Tc sestamibi SPECT/CT accurately located the IPA.

Finally, FNAB of the parathyroid adenoma was reported as a follicular nodule of the thyroid, since follicular cells, such as the parathyroid cells in general, tend to be very similar in morphology to cytological evaluation.[5] A finding that could differentiate them is that the parathyroid cells are generally smaller than the thyroid cells and have less cytoplasm and more chromatin; however, this is not a specific sign.[5],[6]

Learning points:

  • The treatment of persistent or recurrent primary hyperparathyroidism requires exact preoperative localization of pathologic gland
  • To localize a parathyroid adenoma, neck ultrasonography and 99m Tc sestamibi SPECT/CT parathyroid scintigraphy should be performed before surgery.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ruda JM, Hollenbeak CS, Stack BC Jr. A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg 2005;132:359-72.  Back to cited text no. 1
    
2.
Prasad B, Fleming RM. Intrathyroidal parathyroid adenoma. Clin Nucl Med 2005;30:467-9.  Back to cited text no. 2
    
3.
García-Talavera P, Díaz-Soto G, Montes AA, Villanueva JG, Cobo A, Gamazo C, et al. Contribution of early SPECT/CT to 99mTc-MIBI double phase scintigraphy in primary hyperparathyroidism: Diagnostic value and correlation between uptake and biological parameters. Rev Esp Med Nucl Imagen Mol 2016;35:351-7.  Back to cited text no. 3
    
4.
Roy M, Mazeh H, Chen H, Sippel RS. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg 2013;37:102-6.  Back to cited text no. 4
    
5.
Sung S, Saqi A, Margolskee EM, Crapanzano JP. Cytomorphologic features distinguishing Bethesda category IV thyroid lesions from parathyroid. Cytojournal 2017;14:10.  Back to cited text no. 5
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6.
Heo I, Park S, Jung CW, Koh JS, Lee SS, Seol H, et al. Fine needle aspiration cytology of parathyroid lesions. Korean J Pathol 2013;47:466-71.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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