[65-year old female patient with persistent hypercalcemia]

Area of Science:

• Endocrinology
• Surgical Oncology
• Nuclear Medicine

Background:

• Primary hyperparathyroidism is characterized by excessive parathyroid hormone (PTH) production, leading to hypercalcemia.
• Surgical exploration is the standard treatment, but locating the source of excess PTH can be challenging, especially with ectopic adenomas.
• Multinodular goiter can complicate neck surgery, potentially obscuring parathyroid glands.

Observation:

• A 65-year-old patient presented with hypercalcemia and elevated PTH levels, initially suspected to have primary hyperparathyroidism.
• Initial surgical exploration during a thyroidectomy for multinodular goiter failed to identify a parathyroid adenoma.
• Advanced imaging, including technetium-99m sestamibi scintigraphy with SPECT, ultrasound, CT scan, and selective venous sampling, was employed for localization.

Findings:

• An ectopic parathyroid adenoma was successfully localized to the submandibular region of the left jaw.
• Surgical reexploration confirmed and removed the ectopic adenoma.
• Postoperatively, PTH levels normalized, and the patient experienced symptomatic hypocalcemia requiring temporary calcium supplementation.

Implications:

• This case highlights the importance of considering ectopic parathyroid adenomas in cases of persistent hyperparathyroidism after negative neck exploration.
• Advanced imaging techniques are crucial for localizing rare ectopic adenomas.
• Successful management of ectopic parathyroid adenomas can be achieved with thorough diagnostic workup and tailored surgical reintervention.