Challenging Medical and Surgical Management of Ectopic Parathyroid Hormone (PTH) Adenomas in the Elderly

Ectopic parathyroid adenomas (EPAs) are rare and difficult to localize, making surgical cures challenging on the first attempt. However, the management of EPAs in the literature on the geriatric population is limited. Herein, we report two elderly cases of EPAs in atypical locations and challenging management with a mini review of the literature. An 82-year-old English male presented with confusion and constipation, and his tests confirmed primary hyperparathyroidism (PHPT). However, IV fluids and IV bisphosphonate treatment did not treat his hypercalcemia and imaging investigations could not localize parathyroid adenoma (PA); therefore, he underwent explorative left-sided parathyroidectomy, which confirmed normal parathyroid gland. His hypercalcemia improved shortly after surgery; nonetheless, a month later, he was readmitted with recurrent hypercalcemia symptoms. Single-photon emission computed tomography (SPECT) showed a nodule in the mediastinum referring to EPA. But the patient refused the second mediastinal surgery, and after MDT discussion, medical treatment with Cinacalcet was started. Finally, his calcium was normalized under this treatment and remains so. A 69-year-old Turkish female presented with generalized bone pain, and she was diagnosed with PHPT. Her imaging investigations showed only one 1.6cm nodule in the thyroid, and no PA was detected. Further, fine needle aspiration parathyroid hormone (PTH) wash-out from that thyroid nodule showed very high PTH levels, referring to the thyroid's EPA. Meanwhile, she was screened for complications of PHPT, and nephrolitiasis and kyphosis due to severe osteoporosis were found. She underwent minimally invasive surgery under local anesthesia due to severe kyphosis for this EPA, which was confirmed by histopathology. Her PTH and calcium levels normalized shortly after surgery. In limiting imaging results, PTH wash out could be helpful in diagnostic challenges, especially in suspected nodules/lesions in the neck. For the elderly, the value of surgery in achieving a cure is less straightforward than for the young. Thus, treatment of EPAs in the elderly should be decided based on comorbidities, difficult atypical localizations of EPAs and patients' preferences.