Simultaneous intrathyroidal parathyroid adenomas and multifocal papillary thyroid carcinoma in a patient with kidney transplantation: a case report

Abstract

BackgroundPersistent hyperparathyroidism after kidney transplantation has been associated with adverse outcomes. Parathyroidectomy is the definitive treatment approach, but the success of parathyroidectomy relies on the accurate preoperative localization of the culprit parathyroid lesions. Simultaneous intrathyroidal parathyroid adenomas and multifocal papillary thyroid carcinoma present important diagnostic challenges. Here, we describe a patient with kidney transplantation who underwent successful surgery after being evaluated with functional and structural imaging.Case presentationA 53-year-old man presented with potentially malignant multifocal thyroid nodules by ultrasonography 2 years after kidney transplantation. The patient had hypercalcaemia and persistent hyperparathyroidism. Thyroid papillary carcinoma was confirmed in the left thyroid nodules by fine-needle aspiration biopsy. The right superior thyroid hypoechoic nodule was 1.2 cm in size and showed marked uptake of the tracer 99mTcO4-sestamibi during single-photon emission computed tomography/computed tomography (SPECT/CT); additionally, a cystic parathyroid lesion without tracer uptake was present behind the left superior pole of the thyroid. The histological examination demonstrated the coexistence of right intrathyroidal parathyroid adenomas, left cystic parathyroid nodular hyperplasia and multifocal papillary thyroid carcinoma. At the 6-month follow-up, the serum calcium levels were within the normal range, and the patient’s kidney function remained stable.ConclusionsSimultaneous intrathyroidal parathyroid adenomas and multifocal papillary thyroid carcinoma in a patient with kidney transplantation is a rare clinical scenario. Physicians must be aware that the combination of functional (SPECT/CT) and structural (ultrasonography) imaging is highly successful in diagnosing patients with coexistent intrathyroidal parathyroid adenomas and papillary thyroid carcinoma.

Incidentally detected follicular thyroid carcinoma mimicking parathyroid adenoma on Tc-99m MIBI scan: A case report

“…Although encountering tumor imaging using Tc-99m MIBI is rare, nuclear physicians should be aware that tumors rich in mitochondria, such as thyroid carcinoma, lymphoma, and brain tumors, could exhibit high uptake of Tc-99m MIBI. [12][13][14] Although there have been reports on patients with concurrent parathyroid adenoma and thyroid carcinoma, [15,16] distinguishing the 2 based on imaging remains challenging. We misdiagnosed thyroid carcinoma as a parathyroid adenoma located within the thyroid gland and missed the presence of a small parathyroid adenoma on the contralateral side.…”

A Silent Non-thyroidal Adenoma in the Thyroid

“…Parathyroid glands originate from third and fourth pharyngeal pouches [4]. The primordium getting trapped within thyroid during fusion of medial and lateral lobes has been proposed to be the cause of ETPG [5,6]. ETPG may be missed on imaging due to small volume, lack of clinical experience, rarity, and tissue interference of thyroid parenchyma.…”

“…The incidence of IPA has been reported to be 1-6.7% [5,6,8]. Ultrasound can be used as a primary tool for diagnosing parathyroid lesions; it is cost-effective, devoid of radiation, real-time, with 76% sensitivity, provides details regarding sectional anatomy and the surrounding tissue.…”

“…It further allows classification of IPA as partial or complete, based on degree of envelopment by thyroid gland [8]. However, USG may fail to detect IPA in the setting of multiple thyroid nodules or ectopic sites [6,7]. Color Doppler can be used to identify a polar feeding vessel in IPA with co-existent thyroid nodule [8] IPA is hypoechoeic on USG [5,8] with a hyperechoeic line representing the capsule echo of thyroid and parathyroids.…”

“…Tc-99 m sestamibi-scintigraphy with single photon emission computed tomography (sestamibi-SPECT) has high sensitivity (84%) for intrathyroidal parathyroid lesions. The drawbacks include low specificity, high cost and inability to detail sectional anatomy [6,7]. A combination of ultrasound and sestamibi-SPECT (91% sensitivity) may be beneficial in diagnosis [4,7].…”