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57-YEAR-OLD WOMAN WITH PRIMARY HYPERPARATHYROIDISM
Authored By: Keith Fischer and Asif Moinuddin.
Patient: 57 year old female
History: 57-year-old woman with primary hyperparathyroidism.
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Fig. 1

Fig. 2

Fig. 3
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Findings:

RADIOPHARMACEUTICAL: 20.6 mCi Tc-99m sestamibi i.v.


FINDINGS:  Neck planar (Fig 1) and SPECT images performed at 15 minutes after injection of the isotope (Fig 2) demonstrate a focus of increased activity just superior and lateral to the left lobe of the thyroid gland. However, this lesion demonstrates washout similar to the thyroid on two-hour delayed imaging and is therefore atypical in appearance for a thyroid adenoma.

DDx: Parathyroid adenoma, parathyroid hyperplasia, thyroid carcinoma, thyroid adenoma, and parathyroid carcinoma are all considerations.
Diagnosis: An ultrasound examination of the neck (Fig 3) confirms the presence of a hypoechoic nodule anterior to the carotic artery consistent with an adenoma of a non-descended left upper parathyroid gland.
General Discussion: DISCUSSION:
80-85% of parathyroid adenomas are found in close proximity to the thyroid gland. About 15-20% can be found at ectopic locations such as the anterior and posterior mediastinum, within or lateral to the carotid sheath, anterior to the carotid bifurcation, and intrathyroidal*. More commonly, the differential washout of radiopharmaceutical from the thyroid (early) and hyperfunctioning parathyroid gland (late) helps in the evaluation of parathyroid adenoma. However, there are cases in which early washout from a parathyroid adenoma has been described**.

FOLLOW-UP:
Patient underwent surgical resection. Surgeons found an undescended parathyroid just anterior and medial to the carotid well above the left thyroid lobe.  It weighed 860 milligrams.  Intraoperative PTH dropped from 1807 pg/ml basal to 33 pg/ml 11 minutes after adenoma removal. Pathological examination revealed a hypercellular parathyroid gland consistent with an adenoma.
Specific Discussion: For a detailed discussion on parathyroid adenoma, please click on the following link

http://gamma.wustl.edu/pa005te165.html
References: *Mariani G et al. Preoperative Localization and Radioguided Parathyroid Surgery; JNM Vol. 44 No. 9 1443-1458
**Bénard F et al. Rapid Wash-out of Technetium-99m-MIBI from a Large Parathyroid Adenoma. JNM Vol. 36, pp. 241–243.
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Additional Details:

Case Number: 93580Owner(s): Keith Fischer and Asif MoinuddinLast Updated: 02-07-2013
Anatomy: Face and Neck   Pathology: Neoplasm
Modality: Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: panm, parathyroid adenoma, parathyroid hyperplasia, hypercellular, thyroid carcinoma, thyroid adenoma, ectopicACR: 10000.53100

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Certified by Keith Fischer on 11-02-2010

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