Illustrative Cases


Missed Large Cervical Adenoma

A 44-year-old woman had persistent symptomatic hypercalcemia after two unsuccessful cervical explorations for primary HPT with removal of an enlarged left superior parathyroid gland and identification of all except ihe right inferior parathyroid gland. The diagnosis of persistent primary HPT was reconfirmed biochemically. Review of the previous pathology revealed a normal left superior gland. US of the neck revealed a 2- x 5.4- x 1.7-cm nodule posterior to the lower pole of the right lobe of the thyroid and TSS confirmed a suspicious lesion in the corresponding area (Fig. 58-2). At the time of cervical reexplorution, a 7.8-g parathyroid adenoma was found in the right tracheoesophageal groove, which was excised expeditiously. Postoperatively, the calcium level returned to normal.


Mediastinal Adenoma

A 35-year-old man with a history of a kidney stone in his ureter was referred for persistent primary HPT after cervical exploration. During the initial cervical exploration. which was judged to he reasonably complete, all four glands were visualized, and biopsy of the left inferior gland confirmed normal parathyroid tissue. Alter the biochemical diagnosis of primary HPT was reconfirmed, US revealed no abnormality, whereas TSS showed a suspicious uptake in the mediastinum near the left main bronchus (Fig. 58-3). although the CT scan failed to demonstrate any definite abnormal mediastinal gland. Mediastinal exploration was performed that revealed a 2()-g intrathymic parathyroid adenoma. The adenoma was excised, and the patient's calcium level relumed to normal postoperatively.

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