Endocrine Abstracts

Introduction: The prevalence of primary hyperparathyroidism is increasing owing to the more the routinely measurements of serum calcium. A single benign para-thyroid adenoma is the most frequent cause of sporadic PHPT. Primary hyperparathyroidism can also be due to ectopic mediastinal parathyroid adenoma in 11-25% of patients, more frequently involving inferior parathyroid translated in anterior mediastinum. In general to detect ectopic adenoma recent guidelines recommend the use of high resolution neck ultrasound, technetium-99 m-sestamibi subtraction scintigraphy, and contrast-enhanced four-dimensional (4D) computed tomography (CT). The use of endoscopic ultrasound (EUS) is reported in some case reports in literature and some cases in has been integrated with fine-needle aspiration and PTH sampling in the eluate.

Case report: A 68-year old female was admitted in our department for a spontaneous neck hematoma. She was overweight and had parossistic atrial fibrillation (she was not taking anticoagulative drugs), and dyslipidaemia. Laboratory exams revealed primary hyperparathyroidism with elevated total serum calcium 10, 9 mg/dl (8, 8-10, 1), decreased serum phosphorus 2, 1 mg/dl (2, 5-4, 5) and high parathormone 150 pg/mL (12-72). Neck ultrasound did not show images compatible with parathyroid, but a multinodular goitre. Computed tomography of neck revealed complex vascular anatomy of the thyroidal vascularization and a fusiform nodule between posterior side of right thyroid lobe and paraesophageal region, which was compatible with parathyroid gland (axial diameters were 18*12 mm). A double-tracheant scintigraphy revealed a 15 mm nodule in right posterolateral paraesophageal compatible with ectopic parathyroid. A echoendoscopy detected a dysomogeneus, hyperechoic and elonged lesion was noted, with iperenhancement using ultrasonographic contrast media (CEUS). FNAB was performed without complications. The cytological exam revealed minute and rare non-atypical epithelial aggregates, results at PTH + and TTF1 – at immunophenotypic investigations. PTH dosage on the washing liquid was > 2500 pg/ml, diagnostic of ectopic parathyroid.

Conclusions: In selected patients with primary hyperparathyroidism, second and third level diagnostic procedures as in this case could be useful to be sure of diagnosis, in particular if pluricomorbid and frail patients must receive parathyroidectomy with major surgery could include potential severe complications.