Giant parathyroid adenomas constitute a rare clinical entity, particularly in the developed world. We report the case of a 53-year-old woman where the initial ultrasonography significantly underestimated the size of the lesion. The subsequent size and weight of the adenoma (7cm diameter, 27g) combined with the severity of the hypercalcaemia raised the suspicion for the presence of a parathyroid carcinoma. This was later disproven by the surgical and histological findings. Giant parathyroid adenomas are encountered infrequently among patients with primary hyperparathyroidism, and appear to have distinct clinical and biochemical features related to specific genomic alterations. Cross-sectional imaging is mandated in the investigation of parathyroid adenomas presenting with severe hypercalcaemia as ultrasonography alone can underestimate their size and extent. This is important since it can impact on preoperative preparation and planning as well as the consent process as a thoracic approach may prove necessary for certain cases. KEYWORDSParathyroid adenoma -Giant -Primary hyperparathyroidism -Surgery -Imaging -Consent Accepted 11 January 2015; published online XXX CORRESPONDENCE TO George Garas, E: g.garas@imperial.ac.uk Primary hyperparathyroidism (pHPT) is the third most common endocrine disorder and the leading cause of hypercalcaemia among ambulant patients. It primarily affects women with a female-to-male ratio of 4:1 and a peak incidence around the fifth decade of life.1 In the majority (80-85%) of cases, it results from a single parathyroid adenoma while parathyroid hyperplasia (15%) and carcinoma (<1%) represent rarer causes of pHPT. Giant parathyroid adenomas have variable definitions in the literature but the most commonly used is that for adenomas exceeding 3.5g in weight. 2,3Case HistoryA 53-year-old woman was referred to the endocrinology department for investigation and management of newly diagnosed hypercalcaemia. She reported suffering from fatigue as well as generalised bone and muscle pain over the preceding three months. Her past medical history included controlled hypertension. A 2-3cm left neck mass was palpable on cervical examination. The remainder of the physical examination was unremarkable. Laboratory evaluation was consistent with pHPT as she suffered from severe hypercalcaemia (adjusted serum calcium: 15.9mg/dl, normal range: 8.4-10.5mg/dl) associated with exceedingly high parathyroid hormone (PTH) levels measuring 4,038pg/ml (normal range: 10-65pg/ml). In view of the severe hypercalcaemia, the patient was admitted to hospital and started on intravenous fluids followed by a bisphosphonate infusion. Within two days of hospitalisation, the adjusted serum calcium had normalised.In order to investigate the pHPT, neck ultrasonography was initially performed. This revealed a lobular, well defined hypoechoic lesion situated behind the left lower pole of the thyroid gland and measuring 2.85cm in diameter (Fig 1). The severity of the hypercalcaemia made parathyroid carcinoma an important ...

Obstructing colorectal carcinoma seems to be associated with high mortality rate, but long-term survival seems to be the same with non-obstructing carcinoma.

Primary hepatic gastrinoma is a very rare ectopic gastrinoma with less than 20 cases reported worldwide. We report the case of a patient with hypergastrinemia who was subjected to exhaustive preoperative and intraoperative imaging and also careful surgical exploration of the duodenum and pancreas which failed initially to identify the primary tumour. Eventually the patient was subjected to left liver lobectomy, as a small palpable lesion was noted intraoperatively. The diagnosis of gastrinoma requires a high index of clinical suspicion and the flawless cooperation of many specialties.

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