Endocrine Abstracts

Introduction: Ectopic parathyroid glands can occur early during embryological development¹. Their localisation and surgical management may prove challenging if required to cure hyperparathyroidism.

Case report: A 53-year-old lady presented with non-specific aches and pains, she was biochemically diagnosed with primary hyperparathyroidism and bone densitometry confirmed osteoporosis at femoral neck. Surgery was planned in view of young age, high fracture risk and persistent symptoms. An ultrasound scan did not identify an adenoma in the neck, but SPECT-CT/parathyroid scintigraphy demonstrated faint uptake in the anterior mediastinum. While further management plan was being discussed, she was admitted to a mental health ward with psychotic depression. Her serum calcium rose to >3.0mmol/L and she was commenced on cinacalcet. After discharge, when she was clinically and biochemically stable, she had a 4D-CT scan which confirmed an 8mm nodule in the anterior mediastinum corresponding to the area of abnormal uptake on scintigraphy, consistent with an ectopic parathyroid adenoma. However, with a potential for open-chest surgery, surgeons sought further confirmation. A C¹¹-methionine PET scan confirmed that the gland identified was highly likely to be an ectopic parathyroid adenoma. The adenoma was successfully removed with robotic surgery, obviating the need for open surgery and she was confirmed to have been cured by histological and biochemical criteria.

Conclusion and discussion: Ectopic parathyroid glands pose a diagnostic and therapeutic challenge. In this case ultrasound, scintigraphy, 4D-CT, and ultimately C¹¹-methionine PET scan were needed for definite localisation. Robotic surgical techniques saved this lady from having a sternotomy. There was added interest of the psychiatric illness, which was possibly exacerbated by hypercalcaemia, but certainly made her hypercalcaemia worse.¹Chan TJ, Libutti SK, McCart A, Chen C, Khan A, Skarulis MK et al. Persistent primary hyperparathyroidism caused by adenomas identified in pharyngeal or adjacent structures. World J Surg. 2003. 27(6):675-9