Parathyromatosis Following Endoscopic Parathyroid Surgery: A Rare Occurrence

Recurrent parathyromatosis in a patient with concomitant MEN1 and CASR gene alterations: Clinical management of a case report and literature review

Introduction

Parathyromatosis is a rare cause of primitive hyperparathyroidism characterized by the presence of numerous parathyroid tissue foci in the neck/mediastinum, due to hyperplasia of parathyroid embryologic residues (primary-form) or to local parathyroid tissue implantation (secondary-form). 63 cases have been described in the literature. In our patient parathyromatosis was due to a combination of two mutations.

Case report

A 36-years-old woman was diagnosed with osteoporosis secondary to primary hyperparathyroidism. Subsequent right parathyroidectomy showed a parathyroid adenoma. The follow-up was negative but after 10 years she had a relapse. The genetic screening showed a rare intronic mutation of the MEN1 gene and a heterozygous mutation never described in exon 8 of the CASR gene, coding for the calcium receptor. Calcemia and PTH increased over the years with the onset of nephrocalcinosis and the worsening of osteoporosis despite the therapy with Cinacalcet, bisphosphonates and Vitamin D. She had therefore two additional surgical procedures (parathyroid tissue without malignancy). At follow-up she showed elevated levels of PTH (>1000 pg/ml) and calcium (11.2 mg/dl) and CT scans multiple subcentimetric nodules in the neck/upper mediastinum. Since the 68Ga-DOTATATE showed an increased uptake in the neck/mediastinum, lanreotide was added. After two months there was a significant biochemical response but, unfortunately, after six months, the patient showed a new worsening.

Conclusions

a rare case of parathyromatosis due to a combination of two genetic alterations never described. The main issues concern the diagnosis and the radical treatment. Somatostatin analogues may have a useful role in both diagnosis and therapy.

Radiofrequency ablation of parathyroid adenomas causing primary hyperparathyroidism: A report of 27 patients

PURPOSE

To study treatment outcome of parathyroid adenomas using ultrasound-guided radiofrequency ablation.

METHODS

Twenty-seven patients with a single adenoma of the parathyroid gland were included in the study. Using color Doppler ultrasonography, the lesion and its characteristics were determined, and dextrose was injected to dissect the gland from the surrounding structures. The ablation process was done with 6-12 watts of power.

RESULTS

No complications were seen in any of the subjects. A significant reduction was seen in serum parathyroid hormone (PTH) and calcium levels after treatment. PTH levels showed a median decrease of 13.8%, and a median decrease of 8.2% was seen in serum calcium levels (p < 0.001). Phosphorus levels did not change significantly after treatment. In 1-month follow-up of patients, the lesion size had decreased considerably. In long-term follow-up, 11 of 20 patients having subsequent imaging had indistinguishable lesions.

CONCLUSION

Our results showed that RFA of parathyroid adenomas caused a significant reduction in biomedical indicators of disease and resulted in a significant reduction or disappearance of the lesion in the majority of the patients while having no considerable complications.

Parathyromatosis: a very rare cause of recurrent primary hyperparathyroidism - case report and review of the literature

Parathyromatosis is a rare entity and usually appears as a consequence of the seeding on previous parathyroid surgery which was applied for the secondary hyperparathyroidism. A 63-year-old woman presented with a history of subtotal thyroidectomy 20 years ago and parathyroidectomy due to primary hyperparathyroidism (PHPT) four years ago. Imaging methods revealed multiple parathyromatosis foci on subcutaneous tissue of the neck. En-bloc resection was performed and pathological examination confirmed the diagnosis of parathyromatosis. After an uneventful 10 months, biochemical and radiological tests revealed recurrence on bilateral thyroid lodges. En-bloc resection was performed. The patient has remained well for 24 months after the second operation and has been followed-up with normal parathormone and serum calcium values. To the best of our knowledge, this report describes the twenty-first case of parathyromatosis in PHPT setting in the literature. It should be kept in mind that parathyromatosis may recur at different sites in the neck even in patients with PHPT.