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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Primary hyperparathyroidism due to a Parathyroid adenoma .
Primary hyperparathyroidism due to a Parathyroid adenoma .
Contributed by Akash Geet
Contributed by Akash Geet
Clinical Profile:
Clinical Profile:
A 19 year old lady presented with the complaints of multiple joint pains, weakness and loss of appetite since the last last three years.
A 19 year old lady presented with the complaints of multiple joint pains, weakness and loss of appetite since the last last three years.
The symptoms have gradually progressed with time to the extent that she is now unable to walk since the last four months. She also complains of multiple episodes of abdominal pain and vomiting in the recent past. She visited number of local practitioners, however there was no relief.
The symptoms have gradually progressed with time to the extent that she is now unable to walk since the last four months. She also complains of multiple episodes of abdominal pain and vomiting in the recent past. She visited number of local practitioners, however there was no relief.
Radiological Investigations:
Radiological Investigations:
Patient had undergone an X Ray of the left knee joint for these complaints one year ago.
Patient had undergone an X Ray of the left knee joint for these complaints one year ago.
Fig. 1 . •The Radiographs of knee reveal geographic osteolytic expansile lesion with cortical thinning in distal metaphysis of left femur with minimal sclerotic margins. There is no periosteal reaction and the surrounding soft tissue is normal.
The treating physician planned to investigate further and requested radiographs of both knee joints , hands and pelvis with hips.
The treating physician planned to investigate further and requested radiographs of both knee joints , hands and pelvis with hips.
Fig. 2 The frontal radiograph of right hand shows diffuse osteopenia with sub-periosteal bony resorption on the radial aspect of middle phalanges. Acro-osteolysis is seen
Fig. 3 Radiograph of both knee joints show persistence of left distal metaphyseal femoral lesion with an another similar lesion in right distal femur. Zone of transition is narrow. There is no periosteal reaction and the surrounding soft tissue is normal.
Fig. 4 Frontal radiograph of pelvis with both hip joint shows well defined lytic lesion in left iliac blade. Zone of transition is narrow. There is no periosteal reaction and the surrounding soft tissue is normal.
Fig. 5 CECT neck Axial section show a 1.2 x 2 cm sized well defined enhancing lesion posterior to left lobe of thyroid gland s/o parathyroid adenoma
Radiological Diagnosis:
Radiological Diagnosis:
Primary hyperparathyroidism
Primary hyperparathyroidism
Blood biochemistry
Blood biochemistry
Based on the radiographic findings diagnosis of hyperparathyroidism with multiple brown tumours was made.
Based on the radiographic findings diagnosis of hyperparathyroidism with multiple brown tumours was made.
Biochemical investigations were advised for further confirmation. Following were her biochemical parameters:
Biochemical investigations were advised for further confirmation. Following were her biochemical parameters:
Serum calcium - 10 mg % ( N )
Serum calcium - 10 mg % ( N )
Serum phosphorous - 1.4 mg % ( L )
Serum phosphorous - 1.4 mg % ( L )
Serum ALP - 1052 U/L ( H )
Serum ALP - 1052 U/L ( H )
Serum PTH - 250 pg/ml ( H )
Serum PTH - 250 pg/ml ( H )
Vitamin D – 12 ng/ml ( L )
Vitamin D – 12 ng/ml ( L )
T3 , T4 and TSH – ( N )
T3 , T4 and TSH – ( N )
CECT parathyroid protocol was advised.
CECT parathyroid protocol was advised.
Treatment:
Treatment:
The patient underwent tumour excision.
The patient underwent tumour excision.
Fig. 6 Gross specimen shows an approximately 2x1cm sized, well circumscribed mass with a thin capsule
Pathological diagnosis
Pathological diagnosis
ig. 7 The low power magnification scanner view show a well encapsulated lesion with no capsular invasion. Also there is no vascular invasion s/o benign nature of the lesion. The high power magnification image show cellular homogenous lesion composed of polygonal cells with small central nucleus and low level of secretory granules (s/o chief cell) in delicate capillary network. The cell show minimal mitotic activity.
Final diagnosis :
Final diagnosis :
Solitary parathyroid adenoma, primary hyperparathyroidism
Solitary parathyroid adenoma, primary hyperparathyroidism
Discussion:
Discussion:
Solitary parathyroid adenoma is most common cause of primary hyperparathyroidism constituting 80% of all cases (1)
Solitary parathyroid adenoma is most common cause of primary hyperparathyroidism constituting 80% of all cases (1)
Manifestation(2) :
Manifestation(2) :
Renal – nephrolithiasis, nephrocalcinosis, recurrent UTI (secondary to nidus formation), polyurea and dehydration.
Renal – nephrolithiasis, nephrocalcinosis, recurrent UTI (secondary to nidus formation), polyurea and dehydration.
Musculoskeletal – osteoporosis, osteitis fibrosa cystica, muscular weekness, myalgia, arthralgia, arthritis.
Musculoskeletal – osteoporosis, osteitis fibrosa cystica, muscular weekness, myalgia, arthralgia, arthritis.
Gastrointestinal – abdominal pain, constipation, anorexia, nausea, vomiting, peptic ulcer disease, pancreatitis.
Gastrointestinal – abdominal pain, constipation, anorexia, nausea, vomiting, peptic ulcer disease, pancreatitis.
Neuro-psychiatric – memory impairment, depression, anxiety, confusion, stupor, coma.
Neuro-psychiatric – memory impairment, depression, anxiety, confusion, stupor, coma.
Cardiovascular – hypertension.
Cardiovascular – hypertension.
The management of solitary parathyroid adenoma:
The management of solitary parathyroid adenoma:
Long-term medical management is of PHPT is difficult as no agents are available to suppress hypercalcaemia or completely block PTH release.
Long-term medical management is of PHPT is difficult as no agents are available to suppress hypercalcaemia or completely block PTH release.
An asymptomatic patient can be followed up with-
An asymptomatic patient can be followed up with-
1) Annual measurement of serum calcium.
1) Annual measurement of serum calcium.
2) Bone mineral density by DEXA every 1 to 2 years .
2) Bone mineral density by DEXA every 1 to 2 years .
3) Annual assessment of eGFR and serum creatinine.
3) Annual assessment of eGFR and serum creatinine.
4) Renal imaging or 24-h urine stone profile. (3)
4) Renal imaging or 24-h urine stone profile. (3)
Definitive line of treatment is Minimally Invasive Parathyroidectomy (4)
Definitive line of treatment is Minimally Invasive Parathyroidectomy (4)
References:
References:
1) Dan L. Longe, Anthony S. Fauci. Harrison's principles of internal medicine. 18th edition. New York, McGraw-Hill, Medical Pub. 2012
1) Dan L. Longe, Anthony S. Fauci. Harrison's principles of internal medicine. 18th edition. New York, McGraw-Hill, Medical Pub. 2012
2) Michels TC, Kelly KM. Parathyroid disorders. Am Fam Physician. 2013;88(4):249-257. 9. Rolighed L, Rejnmark L, Christ
2) Michels TC, Kelly KM. Parathyroid disorders. Am Fam Physician. 2013;88(4):249-257. 9. Rolighed L, Rejnmark L, Christ
3) 19. Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3561-3569. 20. Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE.
3) 19. Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3561-3569. 20. Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE.
4) Scott M. Wilhelm. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism, AAES Guidelines for Primary Hyperparathyroidism Management. Volume 151. Cleveland, October 2016
4) Scott M. Wilhelm. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism, AAES Guidelines for Primary Hyperparathyroidism Management. Volume 151. Cleveland, October 2016
Acknowledgements:
Acknowledgements:
We are grateful to the department of Surgery at our institution for providing us the image of the operative specimen and to the Department of Pathology for the histology images and the descriptions related to them.
We are grateful to the department of Surgery at our institution for providing us the image of the operative specimen and to the Department of Pathology for the histology images and the descriptions related to them.
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