giant parathyroid adenoma: a case report and review of the ......gland (fig. 1). a parathyroid...

CASE REPORT Open Access

Giant parathyroid adenoma: a case reportand review of the literatureMohamed S. Al-Hassan1, Menatalla Mekhaimar2, Walid El Ansari3,4,5*, Adham Darweesh6 andAbdelrahman Abdelaal1

Abstract

Background: Giant parathyroid adenoma is a rare type of parathyroid adenoma defined as weighing > 3.5 g. Theypresent as primary hyperparathyroidism but with more elevated laboratory findings and more severe clinicalpresentations due to the larger tissue mass. This is the first reported case of giant parathyroid adenoma from theMiddle East.

Case presentation: A 52-year-old Indian woman presented with a palpable right-sided neck mass and generalizedfatigue. Investigations revealed hypercalcemia with elevated parathyroid hormone and an asymptomatic kidneystone. Ultrasound showed a complex nodule with solid and cystic components, and Sestamibi nuclear scanconfirmed a giant parathyroid adenoma. Focused surgical neck exploration was done and a giant parathyroidadenoma weighing 7.7 gm was excised.

Conclusions: Giant parathyroid adenoma is a rare cause of primary hyperparathyroidism and usually presentssymptomatically with high calcium and parathyroid hormone levels. Giant parathyroid adenoma is diagnosed byimaging and laboratory studies. Management is typically surgical, aiming at complete resection. Patients usuallyrecover with no long-term complications or recurrence.

Keywords: Giant parathyroid adenoma, Parathyroidectomy, Primary hyperparathyroidism, Minimal invasiveparathyroidectomy, Atypical parathyroid adenoma

BackgroundThe normal parathyroid gland weighs approximately50–70mg. Parathyroid adenomas (PTAs) are usuallysmall, measuring < 2 cm and weighing < 1 gm [1]. GiantPTAs (GPTAs), although rare, are most commonly de-fined as weighing > 3.5 gm, with some reports describingweights up to 110 gm [2, 3]. Both PTA and GPTApresent with the syndrome of primary hyperparathyroid-ism (PHPT), the third most common endocrine disorder[4]. The pathophysiology of PHPT is autologous secre-tion of parathyroid hormone (PTH) by one or more ofthe parathyroid glands [4]. Although PHPT can becaused by parathyroid hyperplasia or carcinoma, how-ever, around 85% of cases of PHPT are due to PTAs,

and the majority of these are because of solitary PTAs,of which GPTA comprise a small number [5].To the best of our knowledge, this case report de-

scribes the first case in the Middle East of a patient withnon-ectopic GPTA presenting with visible neck swelling.This case report also reviews the published literature toreport on the clinical characteristics and typical presen-tation of GPTA as well as diagnosis and treatment.

Case presentationA 52-year-old Indian woman was referred to our SurgicalEndocrinology clinic at Hamad General Hospital in Doha,Qatar. She complained of a neck swelling and generalizedfatigue. Laboratory results showed hypercalcemia and ele-vated PTH. Her past social, environmental, family, andemployment history (housewife) were unremarkable. Shedid not smoke tobacco and never consumed alcohol.There was no past history of symptomatic kidney stones;however, a recent computed tomography (CT) scan of herabdomen and pelvis showed a 2mm non-obstructing

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: [email protected] of Surgery, Hamad General Hospital, Hamad MedicalCorporation, Doha, Qatar4College of Medicine, Qatar University, Doha, QatarFull list of author information is available at the end of the article

Al-Hassan et al. Journal of Medical Case Reports (2019) 13:332 https://doi.org/10.1186/s13256-019-2257-7

http://crossmark.crossref.org/dialog/?doi=10.1186/s13256-019-2257-7&domain=pdfhttp://creativecommons.org/licenses/by/4.0/http://creativecommons.org/publicdomain/zero/1.0/mailto:[email protected]

calculus in the lower pole calyx of her right kidney withno hydroureteronephrosis. Her past medical history indi-cated that she had dyslipidemia, controlled with medica-tion; however, she was not on any other medication. Onphysical examination, a right-sided neck swelling was ob-vious on inspection; on palpation a mobile non-tendernodule could be felt, approximately 3 cm in size. The restof the physical examination was unremarkable. A neuro-logical examination was unremarkable. On admission, herpulse, blood pressure and temperature were normal.Serology laboratory tests showed corrected calcium of

3.12 mmol/L, an intact PTH of 503 ng/L, vitamin D of19.97 nmol/L, and normal thyroid-stimulating hormone(TSH) level. Her renal functions were within normallimits, serum creatinine was 67 μmol/L, and 24-hoururine calcium was 4.30mmol/L per 24 hours. Her completeblood count (CBC) and liver laboratory findings werewithin normal limits. Microbiology laboratory tests werenot deemed necessary.Imaging investigations included an ultrasound of her

neck that showed a complex nodule (4.1 × 2.3 cm) withsolid and cystic components, and vascularity was ob-served in the mid to lower pole of her right thyroidgland (Fig. 1). A parathyroid Sestamibi scan revealedtracer concentration in the thyroid tissues with more in-tense focal uptake observed related to the lateral side ofthe right thyroid lobe (Fig. 2). A delayed scan revealedresidual persistent uptake, corresponding to the initiallydescribed increased focal uptake seen on the early im-ages. These Sestamibi findings were highly suggestive ofa PTA. Ultrasound-guided fine-needle aspiration (FNA)was done but was non-diagnostic.

Surgical techniqueThis patient fitted two of the criteria for surgical man-agement of PTA: (1) she had renal involvement, and, (2)serum calcium was 3.12 mmol/L (> 0.25 mmol/L fromthe upper limit of normal) [6]. She underwent minimallyinvasive parathyroidectomy (MIP) with focused explor-ation and excision of the right PTA under general

anesthesia. A transverse collar incision was made, thesurgery proceeded and the adenoma was identified andexcised (Fig. 3). Intraoperative PTH (ioPTH) monitoringconfirmed the excision of the adenoma as the PTHdropped from the initial pre-excision level of 546 ng/Lto 239 ng/L 10minutes after the excision, and then to161 ng/L 20 minutes after excision, a 70% drop. Intraop-erative frozen sections were sent to the pathology la-boratory that confirmed PTA. Surgery was concluded;our patient recovered without any complications andwas discharged on the second postoperative day. Finalhistopathology of the gland reported a nodule (4 × 2.5 ×1.5 cm) weighing 7.7 gm with histologic features consist-ent with a PTA (Fig. 4). Our patient was followed for atotal of 3 years postoperatively and she remained asymp-tomatic and normocalcemic, without recurrence.

DiscussionA 52-year-old woman presented with a visible palpableright-sided neck mass and generalized fatigue. Ultra-sound showed a complex nodule with solid and cysticcomponents, and a Sestamibi nuclear scan confirmed aGPTA. Focused surgical neck exploration was done anda GPTA weighing 7.7 gm was excised. This case of non-ectopic GPTA is unusual in that it presented mainlywith visible palpable right-sided neck mass, which waslarge to the extent that the initial ultrasound suggestedthat it could be a thyroid nodule.PTAs are well-reported tumors that cause PHPT.

However, when their weight exceeds 3.5 gm, they areclassified as GPTA [2]. Ours weighed 7.7 gm, and is con-sidered a smaller GPTA in relation to other reportedcases [7–9].In terms of presentation, the classic presentation of

PTA is with PHPT accompanied by recurrent kidneystones, and psychiatric, bone, and gastrointestinal symp-toms [4]. However, this full constellation of symptoms israrely seen nowadays due to the more frequent routineassessments of blood chemistries of patients presentingto hospital and clinics. Hence, such early detection has

Fig. 1 Ultrasound of the neck showing complex nodule of the right lobe with solid and cystic components (a) and vascularity (b)

Al-Hassan et al. Journal of Medical Case Reports (2019) 13:332 Page 2 of 9

led to the majority of patients with PHPT now beingidentified early in the asymptomatic stage [4, 10]. How-ever, our review of cases of GPTA published during thelast 10 years (Table 1, 20 case reports, 22 patients withGPTA) shows that only two out of the 22 publishedcases were completely free of signs and symptoms of hy-percalcemia [15, 17]. On the contrary, Table 1 suggeststhat most GPTAs presented symptomatically, rangingfrom vague bone/abdominal pain [5, 11, 18, 24] to moresevere presentations, for example chronic depression, re-current symptomatic kidney stones, and severe gastro-intestinal symptoms [1, 9, 13, 14, 19–22]. Very rarepresentations included hyperparathyroid crisis and acutepancreatitis [1, 10, 16]. Our current patient presentedwith neck swelling and generalized fatigue, and she hada silent kidney stone that was identified by abdominalCT, suggesting that GPTA generally presents symptom-atically or with signs of hypercalcemia. This is probablyrelated to the higher levels of calcium produced by thelarger tumor mass.In terms of physical examination, the majority of

GPTAs in the neck had a visible and palpable mass inthe neck [7, 11, 13, 14, 17, 19, 20, 24, 25]. Their largesize is one of the reasons a clinician may suspect thyroiddisease before reviewing the laboratory results, as palp-able nodules are more common in the thyroid. In ourcase, a swelling was readily visible on inspection andpalpable on physical examination.As for diagnostic laboratory studies, GPTA investiga-

tions start with serum calcium and PTH and proceed to

Fig. 2 Early and late 99mTc-sestamibi scintigraphy parathyroid scan images of neck and mediastinum anteriorly at 20 minutes and 2 hoursshowing increased focal uptake suggestive of right giant parathyroid adenoma

Fig. 3 Giant parathyroid adenoma identified intraoperatively


imaging for localization (Table 1). Hypercalcemia and el-evated PTH are hallmarks of PHPT [4], in agreementwith our review where all cases had elevated calciumand PTH laboratory values [18]. A positive correlationbetween the size of a PTA and preoperative PTH andcalcium levels has also been reported [2, 26, 27]. Calva-Cerqueira et al. (2007) concluded that if preoperativePTH is > 232 ng/L, there is 95% likelihood of finding aPTA weighing > 250mg [28]. This is valuable, as sur-geons can have an idea of tumor size preoperatively. Asfor histopathology, although FNA cytology (FNA-C) isincreasingly used in the diagnosis of parathyroid pathology[29], its limitation is that FNA-C cannot distinguish be-tween different types of parathyroid disease [30]. Our pre-operative FNA-C was non-diagnostic, similar to otherswhere preoperative FNA-C was non-diagnostic [16].In terms of imaging, localizing a GPTA is imperative to

guide management. The most commonly used method isa combination of neck ultrasound and 99mTc-sestamibiscintigraphy (MIBI) scan. The limitation of neck ultra-sound in GPTA is that it may not show the extent of a le-sion; when the GPTA is ectopic, a neck ultrasound willshow no finding [5]. In mediastinal GPTA, neck ultra-sound only rules out a neck lesion but does not otherwiseaid in localization [20–22]. In neck GPTA, the combin-ation of a MIBI scan and neck ultrasound effectively local-izes the GPTA and allows for guided neck exploration[27]. Ultrasound alone predicts GPTA location with 79%accuracy; combining ultrasound, MIBI, and CT increasesthe accuracy of localization to 82% [2]. We agree, as inour patient, that combining neck ultrasound and MIBIscan accurately localizes the GPTA preoperatively. MIBIscans are more likely to localize GPTA in patients withhigher preoperative PTH and larger GPTA size; an aden-oma correctly localized by MIBI has a 95% likelihood ofweighing > 5.5 gm [28]. As for the location, in agreementwith most studies, our GPTA was not ectopic [2]; how-ever, Table 1 shows that the mediastinum is a common lo-cation for ectopic GPTAs, suggesting that such GPTAsarise in the inferior gland [31, 32].

For the management, the 2014 US National Institutesof Health (NIH) guidelines for PTA management are ei-ther medical or surgical if it fulfills specific criteria [6].As with all the cases in Table 1, our case fulfilled thesymptoms and laboratory criteria for surgery. We under-took MIP, in agreement that it is the preferred proced-ure [19], and ioPTH monitoring, to confirm removal ofthe PTA before closure. Although the MIP/ioPTH com-bination is a gold-standard treatment, comparable out-comes of MIP with and without ioPTH monitoring havebeen reported [33], with some studies suggesting thebenefit of ioPTH monitoring is only for patients withequivocal imaging [34]. This might be an importantfeature to consider when institutions seek resourceutilization and cost savings. In agreement with the pointthat ioPTH might be beneficial only in equivocal im-aging findings, ioPTH monitoring seems to have limiteduse in GPTA. Only in five instances was ioPTH mon-itoring undertaken [5, 13, 17, 19, 23] (Table 1), prob-ably because preoperative imaging and intraoperativevisualization in GPTA leave little doubt about the lo-cation [28], and because of a high likelihood of singlegland disease [2]. At our institution, PTA standard in-traoperative practice is ioPTH monitoring and frozen sec-tion to confirm excision.Postoperatively, larger sized PTAs may be associated

with a higher incidence of postoperative hypocalcemia[26]. Table 1 agrees with this, showing that hypocalcemiaoccurred in cases of larger GPTA. Hungry bone syn-drome, a severe but rare form of postoperative hypocalce-mia, occurred in four cases (Table 1), all of which hadGPTAs weighing > 30 gm. Patients with smaller GPTAswere less likely to have postoperative hypocalcemia. Ourpatient presented with a 7.7 gm GPTA, considered asmaller GPTA in relation to other reported cases [7–9],which could explain why it had a less severe presentationas well as outcome after surgery compared with the othercases. Postoperatively, our patient, due to the smallerGPTA, became normocalcemic with normal PTH, andwas not discharged on any calcium repletion therapy. Our

Fig. 4 Excised giant parathyroid adenoma (4 × 2.5 × 1.5 cm)


Table

1Literature

review

:Casestud

iesof

giantparathyroidaden

oma(2009–2019)

Stud

y*Sex

Age

,years

Side

Presen

tatio

nCa

(mmol/

L)/PTH

(ng/L)

Radiolog

yTreatm

ent

IPTH

Dim

ension

s(m

m)

Weigh

t(g)

Patholog

yPo

stop

erative

complications

a

Thyroidal

Agg

arwalet

al.,

2009

[11]

India

F33

LVisiblesw

elling,

palpable

nodu

le,

bone

pain,R

humerus

andR

pelvicfractures

2.65/762

US:well-d

efined

hypo

echo

iclesion

,posterio

rto

leftlobe

thyroid

Parathyroide

ctom

y(not

specified

)—

95×50

×35

102

Chief

cell

aden

oma

Symptom

atic

hypo

calcem

ia

Salehian

etal.,

2009

[12]

Iran

F53

RVisiblesw

elling,

bone

pain,

nausea,vom

iting

,weigh

tloss

3.65/

1624

USne

ck:h

eteroe

choicmass,inferio

rrig

htlobe

(2×4.8×3cm

);99mTc-M

IBI:

abno

rmalcollectionof

tracer

inR

side

ofne

ck

Neckexploration

andparathyroide

ctom

y(collarne

ckincision

)

—55

×35

×20

30PTA

Nil

Sisodiya

etal.,

2011

[13]

India

F52

RRecurren

tvomiting

4.25/598

US:largehypo

echo

iclesion

inrig

htparatrache

alregion

with

retrosternalextension

Parathyroide

ctom

y,low

anterio

rcervicalapproach

Men

tione

din discussion

39×20

×17

——

Hypocalcemia

Asgharet

al.,

2012

[14]

Pakistan

F55

LParathyroidcrisisb

Palpableno

dule

5.75/

1182

US:largecyst(6×3.7cm

)on

leftside

with

thrombo

sisof

IJV;M

IBI:cystic

lesion

inleftside

neck

displacing

the

thyroidglandon

therig

ht;C

T:large

hypo

denselesion

leftside

ofne

ckwith

perip

heralenh

ancemen

t,retrosternal

extensionandmasseffect

with

deviationof

trache

aandthrombo

sis

ofLIJV

Parathyroide

ctom

yT-shaped

incision

10suspicious-lo

oking

lymph

node

salso

removed

from

levels7and8(by

ENTandthoracic

surgeryteam

s)

—110×70

×60

—PTAwith

prom

inen

tcystic

dege

neratio

n;no

lymph

node

metastasis

Nil

Vilallong

aet

al.,

2012

[10]

Spain

F19

LParathyroidcrisis

3.55/

1207

US:47

×22

mm

nodu

lein

left

thyroidlobe

Hem

ithyroide

ctom

y(it

was

intrathyroidal)

Available,

notused

Max.

diam

eter

3070

Intrathyroidal

PTA

Non

eCalcium

IVd1

,orald2

Neago

eet

al.,

2014

[1]

Romania

(3cases)

M/

F/F

57/

60/

33

R/L/

RC1:Bo

nepain,

abdo

minalpain,

nausea,p

alpable

nodu

leC2:Parathyroidcrisis,

palpable

nodu

leC3:Recurren

tkidn

eyston

es,b

rowntumor

oftib

ia

C1:

3.54/

1780

C2:

4.04/863

C3:

3.15/

1174

MIBI:de

tected

aden

omas

inthe3cases

Bilateraln

eck

explorationand

parathyroide

ctom

y

Not

feasiblec

C1:50

×30

×20

C2:55

×40

×30

—

C1:

30.6

C2:

35.2

C3:>

30

2PTA;1

partially

cysticPTA

C1:Hun

gry

bone

ssynd

rome

C2:Mild

hypo

calcem

iaandhu

ngry

bone

ssynd

rome

C3:Mild

hypo

calcem

ia

Haldaret

al.,

2014

[15]

UK

F61

LAsymptom

atic

3.17/

179.2

US:6cm

massin

Linferio

rcervical

locatio

n;MIBI:pe

rsistent

activity

insamelocatio

n;SPEC

T:tubu

larstructure

insupe

riormed

iastinum

Parathyroide

ctom

y(

selective)

4cm

leftcollar

neck

incision

—65

×30

×15

12PTA

Nil

Garas

etal.,

2015

[5]

UK

F53

LBo

nepain,

palpable

nodu

le3.98/

4038

US:lobu

larwell-d

efined

hypo

echo

iclesion

behind

Llower

poleof

thyroid

gland;

MRI:leftinferio

rPTA,exten

dsde

epinto

med

iastinum

Parathyroide

ctom

y(transverse

cervicalincision

)

Don

e–

94%

redu

ction

in25

minutes

Max.

diam

eter

7027

Chief

cellPTA

Nil


Table

1Literature

review

:Casestud

iesof


oma(2009–2019)(Con

tinued)

Stud

y*Sex

Age

,years

Side

Presen

tatio

nCa

(mmol/

L)/PTH

(ng/L)

Radiolog

yTreatm

ent

IPTH

Dim

ension

s(m

m)

Weigh

t(g)

Patholog

yPo

stop

erative

complications

a

Rutledg

eet

al.,

2016

[7]

Ireland

F21

REnlargingne

ckmass,

constip

ation,

palpable

nodu

le

2.73/

1305.1

MIBI:lesion

posteriorto

right

lobe

ofthyroidwith

concen

trated

tracer

Rthyroid

lobe

ctom

yand

parathyroide

ctom

ywith

level6

neck

dissectio

n(suspe

cted

carcinom

a)

—80

×55

×30

58.8

AtypicalP

TASymptom

atic

hypo

calcem

ia,

hung

rybo

nesynd

rome

Krishn

amurthy

etal.,2016

[16]

India

M50

LRecurren

tattacksof

acutepancreatitis,

palpable

fullness

2.77/669

CT:6×4cm

massin

Lparatrache

alregion

with

extensionto

supe

rior

med

iastinum

;PET–C

T:isolated

uptake,

leftparatrache

alregion

;MIBI:localized

toLinferio

rparathyroidgland;

Preo

perativeFN

A-C

was

done

d

Parathyroide

ctom

yviatranscervicalapp

roach

—Max.

diam

eter

6020

PTA

Hypocalcemia

Castroet

al.,

2017

[17]

Spain

F40

LAsymptom

atic,

palpable

nodu

le3.35/825

US:solid

lesion

behind

Lthyroidlobe

;SPEC

T:intenseup

take,b

ackof

Lthyroidlobe

inearly

andlate

phases

Parathyroide

ctom

y(not

specified

)Don

e,90%

redu

ction

64×16

×20

10.8

PTA

Hypocalcemia

Sahsam

anis

etal.,2017

[18]

Greece

F42

LAbd

ominalpain

2.60/151

US:en

larged

parathyroidglandon

lower

side

ofcervicalregion

;MIBI:

largeconcen

trations

ofradiotracer

inthesamelocatio

n

Minim

allyinvasive

parathyroide

ctom

yNot

done

33×20

×14

5.39

PTA

Nil

Mantzoros

etal.,

2018

[19]

Greece

F73

RNecksw

elling,

bone

pain

3.63/

1629

US:hypo

echo

icno

duleat

inferio

rpo

leof

therig

htthyroid;

MIBI:hype

rfunctio

ning

rightlower

parathyroidgland

Minim

allyinvasive

parathyroide

ctom

yDon

e,95%

redu

ction

20minutes

after

removal

50×25

×25

30PTA

Hun

grybo

nesynd

rome

Med

iastinal

Migliore

etal.,

2013

[8]

Italy

F65

RPersistent

hype

rcalcemiae

Both

elevated

CT:7cm

massin

posterior

med

iastinum

;MIBI:confirm

edtheCTfinding

Vide

o-assisted

minith

oracotom

y—

—95

PTA

Nil

Tagh

aviK

ojidi

etal.,2016

[20]

Iran

M70

Mid

Ano

rexia,nausea,b

one

pain,con

stipation,

symptom

atickidn

eyston

es,p

olydipsia

3.60/930

US:multip

leisoe

choicno

dules,no

parathyroidglands

seen

;MIBI:focal

radiotraceraccumulation,

midline

anterio

rchestwall;CT:softtissue

density

mass,mild

enhancem

ent,

anterio

rmidline,xiph

oidlevel

Surgicalremoval

(not

specified

)f

——

75Active

parathyroid

lesion

Hypocalcemia

Pechevaet

al.,

2016

[21]

UK

F72

RDep

ression,

severe

osteop

orosis

(T=−3.2)

3.02/

250.8

US:no

parathyroidlesion

;MIBI:no

eviden

ceof

PTA;C

T:complex

cystic

solid

massin

themed

iastinum

Parathyroide

ctom

yviaVA

TSNot

used

,em

erge

ncy

—19

PTA

Hoarsen

ess,

bovine

coug

h

Talukder

etal.,

2017

[22]

India

F49

Mid

Brow

ntumor

14.07/

1000

US:no

abno

rmalparathyroidgland;

MIBI:tracer-avidlesion

inanterio

rmed

iastinum

;PET-CT:ectopic

parathyroidtissuein

anterio

rmed

iastinum

behind

manub

rium

sterni

Parathyroide

ctom

yviacervicalcollar

incision

and

hemisternotom

y

—40

×30

×20

12Neuroen

docrine

celltumor

Nil


Table

1Literature

review

:Casestud

iesof


oma(2009–2019)(Con

tinued)

Stud

y*Sex

Age

,years

Side

Presen

tatio

nCa

(mmol/

L)/PTH

(ng/L)

Radiolog

yTreatm

ent

IPTH

Dim

ension

s(m

m)

Weigh

t(g)

Patholog

yPo

stop

erative

complications

a

Garun

aMurthee

etal.,2018

[9]

UK

M72

Mid

Ano

rexia,lethargy,

abdo

minalcram

ps,

constip

ation,

weigh

tloss

15.19/

1867.1

CXR

:sizeablemed

iastinalmass;CT:

9cm

solid

cysticanterio

rmed

iastinal

tumor;M

IBI:he

teroge

neou

stracer

uptake

inthemed

iastinalmass

Med

ialsternotom

yandtotalthymectomy

—Maxim

umdiam

eter

78220

IntrathymicPTA

Nil

Miller

etal.,

2019

[23]

UK

M53

Mid

Asymptom

atic

renalstone

s11.22/

179.2

MIBI:linearregion

ofincreased

intensity

intheleftmed

iastinum

Parathyroide

ctom

yviatranscervicale

xcision

Don

e,81%

redu

ction

after10

minutes

80×30

×30

30.9

PTA

Nil

—no

trepo

rted

,can

notbe

inferred

,C1Case1,

C2Case2,

C3Case3,

CTcompu

tedtomog

raph

y,CX

RchestX-ray,EN

Totolaryn

gology

,Ffemale,FN

A-C

fine-ne

edle

aspiratio

ncytology

,IPTHintrao

perative

parathyroidho

rmon

e,IJVinternal

jugu

larvein,L

left,M

male,Mid

midlin

e,MIBIT

c99m-sestamibiscintigraph

yscan

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patient was followed for a total of 3 years postoperativelyand she remained asymptomatic and normocalcemic,without recurrence. This fits with outcomes reported in astudy following patients for an average of 40months,where all patients remained normocalcemic and there wasno recurrence during this time, even in those with suspi-cious histologic features [27].

ConclusionGPTA is a rare subset of PTAs that weigh > 3.5 gm, it isbenign, but can manifest with the symptoms of extremehypercalcemia. From our literature review, we concludethat GPTA generally presents symptomatically, withhigh preoperative PTH and serum calcium directly pro-portional to the adenoma weight. The most accuratemethod for localizing a GPTA is a combination of neckultrasound and MIBI scan. MIP with intraoperative PTHmonitoring is the suggested management, although theneed for the ioPTH monitoring is debatable in GPTAdue to their large size and accuracy of preoperativeimaging.

AbbreviationsCBC: Complete blood count; CT: Computed tomography; FNA: Fine-needleaspiration; FNA-C: Fine-needle aspiration cytology; GPTA: Giant parathyroidadenoma; ioPTH: Intraoperative parathyroid hormone; MIBI: 99mTc-sestamibiscintigraphy; MIP: Minimally invasive parathyroidectomy; NIH: US NationalInstitutes of Health; PHPT: Primary hyperparathyroidism; PTA: Parathyroidadenoma; PTH: Parathyroid hormone; TSH: Thyroid-stimulating hormone

AcknowledgementsNot applicable.

Authors’ contributionsMM and WEA drafted the manuscript; AA contributed to the writing of themanuscript. MM, AA, and MAH acquired the clinical data. WEA, MM, and AAdeveloped the structure and arguments of the paper. WEA, MM, AA, andMAH made important revisions and approved the final version of themanuscript. All authors agreed with the manuscript conclusions andreviewed and approved the final manuscript.

FundingNot applicable

Availability of data and materialsData sharing is not applicable to this article as no datasets were generatedor analyzed during the current study.

Ethics approval and consent to participateEthics approval and consent to publish provided: Medical Research Centrereview board, Institutional Review Board (IRB), protocol #0419113, HamadMedical Corporation, Doha, Qatar.

Consent for publicationEthics approval and consent to publish provided (Medical Research Centrereview board, IRB, #0419113, Hamad Medical Corporation, Doha, Qatar).Written informed consent was obtained from the patient for publication ofthis case report and any accompanying images. A copy of the writtenconsent is available for review by the Editor-in-Chief of this journal.

Competing interestsThe authors declare that they have no competing interests.

Author details1Department of General Surgery, Hamad General Hospital, Hamad MedicalCorporation, Doha, Qatar. 2Weill Cornell Medicine-Qatar, Doha, Qatar.3Department of Surgery, Hamad General Hospital, Hamad MedicalCorporation, Doha, Qatar. 4College of Medicine, Qatar University, Doha, Qatar.5School of Health and Education, University of Skövde, Skövde, Sweden.6Department of Medical Imaging, Hamad General Hospital, Hamad MedicalCorporation, Doha, Qatar.

Received: 11 June 2019 Accepted: 10 September 2019

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https://doi.org/10.1136/bcr-2018-228292https://doi.org/10.1136/bcr-2018-228292

AbstractBackgroundCase presentationConclusions

BackgroundCase presentationSurgical techniqueDiscussionConclusionAbbreviationsAcknowledgementsAuthors’ contributionsFundingAvailability of data and materialsEthics approval and consent to participateConsent for publicationCompeting interestsAuthor detailsReferencesPublisher’s Note

giant parathyroid adenoma: a case report and review of the ......gland (fig. 1). a parathyroid...

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