Recurrent hyperparathyroidism secondary to parathyromatosis: clinical and imaging findings

Persistent and recurrent hyperparathyroidism - Attitude

BACKGROUND

Despite parathyroidectomy represents the curative treatment for primary hyperparathyroidism (pHPT) in up to 98% of patients, persistent hyperparathyroidism (perHPT) and recurrent hyperparathyroidism (rHPT) rates are reported in 22% and 10%, respectively. Indications for reoperation must be balanced with the higher risk of postoperative complications. The aim of this review is summarizing the current evidence in terms of preoperative assessment and surgical approach in patients with perHPT and rHPT.

METHODS

Operations for pHPT between 1997 and 2023 in our center were analyzed and patients with perHPT and rPTH at time of referral were included.

RESULTS

Among 1730 parathyroidectomies for pHPT, 85 patients underwent revisional surgery. Eleven and 74 out of these 85 cases were due to perHPT and rHPT, respectively.

CONCLUSIONS

Prior to reoperation, biochemical assessment and localization methods should always be performed to properly plan surgical strategy. Surgical experience represents the primary determinant in achieving effective disease control.

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.

Parathyromatosis as a cause of recurrence primary hyperparathyroidism: A case report

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Parathyromatosis in primary hyperparathyroidism are a difficult diagnostic and therapeutic task.

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The main method of treatment is the surgical removal of all foci of parathyromatosis.

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In the postoperative period, observation of such patients is required with laboratory and visual screening to exclude recurrence hyperparathyroidism.

Introduction and importance

Parathyromatosis is a rare cause of recurrent hyperparathyroidism. The main cause of this pathology is secondary implantation into the surrounding tissues of the damaged parathyroid gland (rough manipulation of the gland tissue) during the primary operation. Nowadays, parathyromatosis remain a difficult diagnostic and therapeutic task.

Case presentation

A 57-year-old woman 12 years ago underwent right inferior parathyroid adenomectomy. For the last 2 years, the patient began to worry about pain in large tubular bones, thoracic spine. In the biochemical analysis of the patient's blood, the serum ionized calcium level was increased - 1.56 mmol/l, parathyroid hormone - 144 pg/ml. Ultrasound scan of the neck showed the presence of two hypoechoic formations with dimensions of 24 × 12 × 6 mm and 14 × 9 × 8 mm behind the right lobe of the thyroid gland (the site of a previously operation).The patient underwent cervicotomy, removal of 3 fragments of the parathyromatosis tissue. According to a histological study, there fragments are presented by diffuse-nodular hyperplasia from dark main cells. Remission of primary hyperparathyroidism was achieved.

Clinical discussion

This clinical case shows the need for differential diagnosis in recurrence primary hyperparathyroidism with parathyroid cancer, secondary hyperparathyroidism, parathyromatosis.

Conclusion

The main method of treatment is the surgical removal of all foci of parathyromatosis. In the postoperative period, observation of such patients is required with laboratory and visual screening to exclude recurrence hyperparathyroidism.

Persistent secondary hyperparathyroidism caused by parathyromatosis and supernumerary parathyroid glands in a patient on haemodialysis

Background

Secondary hyperparathyroidism (SHPT) is a common high-risk factor for mortality in end-stage renal disease, and parathyromatosis and supernumerary parathyroid glands are very rare causes of persistent SHPT. Preoperative diagnosis and removal of all hyperplastic parathyroid glands are challenging. We report a rare case of persistent SHPT due to parathyromatosis and supernumerary parathyroid glands and successful management by multiple imaging modalities.

Case presentation

A 53-year-old Chinese woman on haemodialysis experienced discomfort due to itching and bone pain due to persistent SHPT after parathyroidectomy. The supernumerary parathyroid glands and parathyromatosis were detected by multiple imaging modalities, including ^99mTc-sestamibi (^99mTc-MIBI) scans, ultrasonography and four-dimensional computed tomography (4D-CT) and then excised; pathological confirmation was performed. During follow-up, her serum calcium and parathyroid hormone levels were stable in the appropriate ranges, and no complications arose.

Conclusions

Because of persistent SHPH after parathyroidectomy in patients with haemodialysis, multiple imaging modalities, including ^99mTc-MIBI scans, 4D-CT and ultrasonography, are helpful for detecting supernumerary parathyroid glands and parathyromatoses. Accurate preoperative localization of this rare lesion is important for management, enabling the removal of all affected parathyroid tissues.

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.

PARATHYROMATOSIS: A RARE CASE OF RECURRENT HYPERPARATHYROIDISM LOCALIZED BY FOUR-DIMENSIONAL COMPUTED TOMOGRAPHY

Objective

To present a rare case of parathyromatosis.

Methods

We present the clinical, laboratory, and imaging findings, along with a review of the literature.

Results

A 33-year-old man with a history of right upper parathyroid adenoma removal 5 years prior due to hyperparathyroidism was admitted for severe hypercalcemia (15.6 mg/dL; normal, 8.5 to 10.5 mg/dL) with elevated plasma parathyroid hormone (PTH) (882 pg/mL; normal, 15 to 65 pg/mL). Ultrasound, computed tomography (CT), sestamibi, and positron emission tomography scans were unremarkable; however, a four-dimensional CT (4DCT) of the neck showed an area of increased signal enhancement and hypervascularity without discrete nodule in the posterior right thyroid region. The patient underwent parathyroid surgical exploration with right hemithyroidectomy and compartment neck dissection to remove the affected tissue. PTH levels dropped to 208 pg/mL postoperatively; calcium decreased but remained elevated at 12.7 mg/dL. Pathology revealed the presence of several small nodular foci of atypical hyperplastic parathyroid tissue in the right thyroid and soft tissue in the left central neck compartment consistent with parathyromatosis.

Conclusion

This case report represents the first-time use of 4DCT to localize parathyromatosis. Parathyromatosis is a rare but problematic cause of recurrent hyperparathyroidism. Ultrasound and 4DCT may represent the best imaging modalities for identification and perioperative management to remove all affected tissue without reseeding.

Recurrent primary hyperparathyroidism due to Type 1 parathyromatosis

Parathyromatosis is a rare condition consisting of multiple nodules of benign hyperfunctioning parathyroid tissue scattered throughout the neck and superior mediastinum. As a potential cause of recurrent or persistent hyperparathyroidism, parathyromatosis is a challenging condition to diagnose and treat. The optimal evaluation and management of patients with parathyromatosis is not well established. The reported case involves a patient who was initially diagnosed with primary hyperparathyroidism. The diagnosis of Type 1 parathyromatosis was made after the patient developed recurrent hyperparathyroidism with hypercalcemia and osteoporosis 17 years after the initial operation and underwent two additional operations. The majority of parathyromatosis cases are diagnosed in the setting of secondary hyperparathyroidism. Consensus regarding the preoperative diagnosis and evaluation is lacking due to the paucity of cases of this rare clinical entity. Management involves complete surgical extirpation of all identifiable rests of parathyroid tissue. Intra-operative parathyroid hormone level monitoring and frozen section examination are excellent tools that could increase the rates of initial operative success. Despite this, long-term disease remission is rare, and medical therapy, including calcimimetics and bisphosphonates, may be required for postoperative or non-operative management.

Hyperparathyroidism caused by distant pulmonary lesions and parathyromatosis after ethanol injection/parathyroidectomy for secondary hyperparathyroidism

Secondary hyperparathyroidism (SHPT) treatment includes parathyroidectomy and percutaneous ethanol injection therapy (PEIT), which are invasive procedures. The condition in which benign hyperfunctioning parathyroid tissue is distributed throughout the neck and mediastinum is termed parathyromatosis. Here, we present the case of a 51-year-old woman who began hemodialysis in 1986 due to chronic kidney disease of unknown etiology and developed SHPT in 1999. She underwent 6 rounds of PEIT followed by total a parathyroidectomy with partial forearm autotransplantation. Between 2011 and 2013, surgeons removed several nodules from her pulmonary and cervical regions and the transplanted masses from her forearm; all showed hyperplasia but exhibited no histological evidence of malignancy. Damage to the parathyroid capsule after repeated PEITs may cause local cervical recurrence and pulmonary lesions, although distant lesions are extremely rare in SHPT. This case is of interest due to the possible association between PEIT and parathyromatosis and distal lesions.

[Parathyromatosis: An uncommon cause of recurrent hyperparathyroidism]

INTRODUCTION

Parathyromatosis is a rare cause of recurrent hyperparathyroidism. It results from hyperfunctioning parathyroid tissue scattered throughout the thyroid bed region.

CASE REPORT

A 51-year-old man with a history of parathyroidectomy, presented 18 years later with recurrent primary hyperparathyroidism. Surgical exploration identified a single parathyroid gland. The act was completed by a central compartment dissection and ipsilateral lobectomy. The patient was free of recurrence after a one-year follow-up.

CONCLUSION

Parathyromatosis a rare cause of recurrent hyperparathyroidism. Its management is challenging. Extensive surgery is required with clearance of the central neck compartment and homolateral lobectomy. Medical therapy could be used to decrease parathormone level in recurrent parathyromatosis.

Parathyroid: The Pathology of Hyperparathyroidism

This review focuses on the pathologic entities associated with hyperparathyroidism in humans. A discussion of the lesions, their embryology, and pathologic features is included. Immunohistology, cytopathology, and a brief overview of molecular aspects of the lesion are included.

Secondary parathyromatosis in a patient with normal kidney function: review of diagnostic modalities and approaches to management

OBJECTIVE

To present a patient with secondary parathyromatosis, a rare complication of parathyroidectomy, and to discuss issues currently pertinent to its diagnosis and management.

METHODS

Data were derived from clinical and pathologic observations obtained during patient care.

RESULTS

The index patient developed intractable hyperparathyroidism and hypercalcemia that has persisted after 4 surgical procedures and has remained largely resistant to medication, albeit with partial amelioration with combined bisphosphonate and cinacalcet.

CONCLUSION

Despite the rarity of this difficult complication of parathyroidectomy, its iatrogenic basis emphasizes a need for heightened awareness and caution among surgeons and endocrinologists. Herein we report an instance of intractable secondary parathyromatosis in a patient with normal kidney function, and we review current approaches to diagnosis and management.

(99m)Tc MIBI SPECT findings in parathyromatosis--a rare entity causing recurrent hyperparathyroidism

Parathyromatosis is a rare clinical condition resulting in recurrent hyperparathyroidism that often poses challenges in its diagnosis and complete surgical cure. We report the (99m)Tc MIBI SPECT findings in a patient with recurrent hyperparathyroidism requiring multiple parathyroid explorations. MIBI SPECT helped localize the areas of these "recurrent parathyroid lesions" that were often found outside of the expected locations within the neck.

Parathyromatosis: a rare yet problematic etiology of recurrent and persistent hyperparathyroidism

Recurrent or persistent hyperparathyroidism is an uncommon yet challenging clinical problem, and parathyromatosis is one of its very rare causes. In this minireview, we review causes of recurrent hyperparathyroidism and all cases of parathyromatosis available in the literature. The clinical course of a case of parathyromatosis with the longest follow-up (1977-2011) is described. Similar cases reported between 1975 and the present are reviewed and analyzed to characterize the clinical presentation, course, and management of this rare condition. Parathyromatosis, which is benign parathyroid tissue seeding, has been detailed in 35 patients in the English literature. The majority were female subjects, with end-stage renal disease, in their fifth to sixth decade of life. In most cases, the diagnosis was made intraoperatively; and the condition was often refractory to surgery. A calcimimetic agent was used in 5 cases with end-stage renal disease; serum calcium and/or parathyroid hormone levels decreased in 4 subjects, but only one was reported to experience increments in bone density. Medical management combining a calcimimetic with a bisphosphonate may therefore be a preferred alternative.