Can a Parathyroid Adenoma cure itself?
A Abbara 1, J Flood1, M Reddy1, T Tatla2, S Mehta1, D Devendra1, D Darko1
1. Department of Endocrinology, Central Middlesex Hospital
2. Department of Ear Nose and Throat Surgery, Central Middlesex Hospital
A 23 year old lady presented with a 2 week history of lethargy, abdominal pain, headaches, polydipisa and polyuria. Blood tests revealed a raised serum calcium of 3.03 (NR 2.15-2.58 mmol/L), phosphate 0.93 (NR 0.74-1.52mmol/L), alkaline phosphatase 78 (NR 40-150IU/L), vitamin D 19 (50-80 nmol/l) and a raised PTH 23 (NR 1.4-6.3 pmol/L).
She had no family history of any endocrine disorders. A screen for MEN was negative and two urinary calcium clearances excluded familial hypocalciuric hypercalcaemia. There was no evidence of nephrocalcinosis on renal ultrasound. A neck ultrasound showed a 2.3cm hypoechoic mass lesion consistent with a superior right parathyroid adenoma. A Sestamibi scan confirmed the diagnosis of a right inferior parathyroid adenoma.
Her case was discussed by endocrinologists, ENT surgeons and radiologists within the thyroid multidisciplinary team meeting and the decision was made to recommend a localised parathyroidectomy of the right inferior parathyroid adenoma with intra-operative examination of the ipsilateral gland. She underwent focussed excision of both the right upper and lower parathyroid glands as they appeared similar intra-operatively.
Histology showed that one gland was normal and healthy, but the other showed a large area of infarction and cystic degeneration, surrounded by a compressed rim of parathyroid tissue with evidence of haemorrhage.
Post-operatively her serum calcium and PTH were normal, however it was retrospectively noted that she had on two occasions a normal calcium and PTH on blood tests taken approximately one week prior to her operation. This in combination with the histology suggested that she may have auto-infarcted her parathyroid adenoma preoperatively.
Although rare, this phenomenon has previously been noted in the literature, initially in 1946(1). Half of patients experience neck pain in a small series (n=11) and 66% of the adenomas were at least 2cm in size (2). Other symptoms and signs suggestive of parathyroid auto-infarction include a neck mass, dysphagia, hoarseness and neck ecchymoses (2). Most patients achieve a permanent cure post infarction, although in a small number of cases the infarction is incomplete and the condition may recur thereafter. Therefore some advocate routine removal post-infarction to ensure cure and for confirmation of the diagnosis (3).
1. Norris EH. Primary hyperparathyroidism. Arch Pathol 1946;42: 261-273.
2. Kovacs, Katherine A. MD; Gay, John D. L. MD, MSc Remission of Primary Hyperparathyroidism Due To Spontaneous Infarction of a Parathyroid Adenoma: Case Report and Review of the Literature Medicine Issue: Volume 77(6), November 1998, pp 398-402
3. Keisuke Kataoka · Manabu Taguchi · Akira Takeshita Megumi Miyakawa · Yasuhiro Takeuchi, Recurrence of primary hyperparathyroidism following spontaneous remission with intracapsular hemorrhage of a parathyroid adenoma J Bone Miner Metab (2008) 26:295–297