Case report: coexistence of primary hyperparathyroidism with giant toxic nodular goiter

Zhang, Wei; Liu, Fangyi; Chen, Kang; Wang, Yajing; Dou, Jingtao; Mu, Yi Ming; Lyu, Zhaohui; Zang, Li

doi:10.1186/s12902-022-01117-0

Cited by 1 publication

(1 citation statement)

References 25 publications

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“…A similar case regarding both parathyroid and thyroid pathological findings was reported in 2023 on a subject who underwent 99mTc-sestamibi scintigraphy: the lack of orthotopic uptake at the level of the thyroid area was associated with an ectopic thyroid tissue that was identified at the lingual level, while, synchronously, there was an ectopic mediastinal parathyroid tumour [73]. Another very rare scenario involves the concomitant diagnosis of PHP and giant-goitre-associated thyrotoxicosis; in this situation, hypercalcaemia-related hyperthyroidism may mask the biological recognition of PHP and 99m-Tc sestamibi scintigraphy might be found as false negative at baseline [74]. Also, 99m-Tc scintigraphy has been used for thyroid hemi-agenesis, showing an increased unilateral uptake amid this interesting developmental disease of the gland [75,76].…”

Section: Ectopic Thyroid Tissuementioning

confidence: 99%

Pitfalls of DualTracer 99m-Technetium (Tc) Pertechnetate and Sestamibi Scintigraphy before Parathyroidectomy: Between Primary-Hyperparathyroidism-Associated Parathyroid Tumour and Ectopic Thyroid Tissue

Carsote,

Stanciu,

Popa

et al. 2023

Medicina

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Diagnosis of primary hyperparathyroidism (PHP) is based on blood assessments in terms of synchronous high calcium and PTH (parathormone), but further management, particularly parathyroid surgery that provides the disease cure in 95–99% of cases, requires an adequate localisation of the parathyroid tumour/tumours as the originating source, with ultrasound and 99m-Technetium (99m-Tc) sestamibi scintigraphy being the most widely used. We aimed to introduce an adult female case diagnosed with PHP displaying unexpected intra-operatory findings (ectopic thyroid tissue) in relation to concordant pre-operatory imaging modalities (ultrasound + dual-phase 99m-Tc pertechnetate and sestamibi scintigraphy + computed tomography) that indicated bilateral inferior parathyroid tumours. A sudden drop in PTH following the removal of the first tumour was the clue for performing an extemporaneous exam for the second mass that turned out to be non-malignant ectopic thyroid tissue. We overviewed some major aspects starting from this case in point: the potential pitfalls of pre-operatory imaging in PHP; the concordance/discordance of pre-parathyroidectomy localisation modalities; the need of using an additional intra-operatory procedure; and the clues of providing a distinction between pathological parathyroids and thyroid tissue. This was a case of adult PHP, whereas triple localisation methods were used before parathyroidectomy, showing concordant results; however, the second parathyroid adenoma was a false positive image and an ectopic thyroid tissue was confirmed. The pre-operatory index of suspicion was non-existent in this patient. Hybrid imaging modalities are most probably required if both thyroid and parathyroid anomalies are suspected, but, essentially, awareness of the potential pitfalls is mandatory from the endocrine and surgical perspectives. Current gaps in imaging knowledge to guide us in this area are expected to be solved by the significant progress in functional imaging modalities. However, the act of surgery, including the decision of a PTH assay or extemporaneous exam (as seen in our case), represents the key to a successful removal procedure. Moreover, many parathyroid surgeons may currently perform 4-gland exploration routinely, precisely to avoid the shortcomings of preoperative localisation.

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