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Case 376

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A 57-year-old female patient initiated diffuse bone pain over a year ago and was admitted to the hospital after presenting with worsening of symptoms, which restricted deambulation. Laboratorial findings showed calcitonin: 15,4mg/dL (reference range: 8,5-10,2mg/dL), PTH: 2566,8pg/mL (reference range: 18,5-88,0pg/mL) and alkaline phosphatase: 1525U/L (reference range: 36-110 U/L). Computed tomography (CT) and magnetic resonance imaging (MRI) of the neck were performed. After hemodynamic and calcium levels stabilization, the patient underwent surgical resection of the lesion.

Considering the clinical history and images presented, what is the most likely diagnosis?

a) Thyroid carcinoma

25%

b) Parathyroid carcinoma

25%

c) Parathyroid adenoma

25%

d) Thymoma

25%
   

Image analysis

Image 1 - Analysis: Sagittal imaging of computed tomography (CT) - (A) and magnetic resonance (RM) of the neck (B), weighed in T2, right paramedian sections, demonstrates heterogeneous, lobulated, partially deligned lesion, localized posterior to the right thyroid lobe and extending towards the lower mediastinum (red arrows)

 

Image 2 - Analysis: Axial imaging of computed tomography (CT), before (A) and after (B) intravenous contrast injection, at level of superior thoracic apertura. The cervical lesion extends towards the superior mediastinum, keeping its multicystic pattern (green circles). It presents with heterogeneous contrast uptake (blue arrows), which demonstrates vascular component with cysts in between, already identified in RMI imaging.

 

Image 3 - Analysis:  Axial computed tomography (CT) imaging of the neck, reconstructed in soft tissue window, before (A) and after intravenous contrast injection (B), and reconstructed in bone window (C). Axial MRI imaging of the neck, weighed in T2 (D) and in T1 (E). The images were acquired at the mandible level. The images demonstrate expansile lesion localized in the mandible ramus (yellow circles), with soft tissue density, contrast uptake and subtle adjacent cortical thinning, without signs of periosteal reaction. MRI demonstrates subtle intermediate signs in T2 e T1 (purple circles), presenting with cortical thinning, without signs of expansion towards the soft tissues of the ipsilateral masticatory apparatus.

 

Image 4 - Analysis: Surgical sampling of parathyroid, measuring 5,5 x 4,0 x 2,5cm and weighing 25,9g, covered by smooth, lustrous capsule; light brown surface with cystic and solid areas in between. Microscopy images of hematoxylin-eosin stained slides, presenting with proliferation of chief cells, without any signs of pleomorphism, atypia, vascular or capsule invasion and mitotic figures, which indicate benign neoplasm.

Highlights

   -  The main cause of hyperparathyroidism corresponds to parathyroid adenoma.

   -  Pathophysiology consists of excessive secretion of PTH, which presents with bone and kidney disease.

   -  The diagnosis is clinical and laboratorial. Imaging studies are useful to determine differential diagnosis and surgical planning.

   -  Management of asymptomatic patients without criteria for surgical resection may be exclusively clinical.

   -  Parathyroidectomy is indicated if a patient presents with symptomatic hypercalcemia or asymptomatic patients with surgical criteria.

References

   -  Brasileiro Filho G. Bogliolo Patologia. 8ª ed. Grupo Gen - Guanabara Koogan; 2000.

   -  Shonni J Silverberg, MD, et al. Primary hyperparathyroidism: Management. Inc. https://www.uptodate.com (Accessed on May 9, 2019.)

   -  Bilezikian et al. Primary Hyperparathyroidism: Management Guidelines. J Clin Endocrinol Metab, October 2014, 99(10):3561–3569

   -  Kronenberg H, Melmed S, Polonsky K, Larsen P. Willians Tratado de Endocrinologia. 11ª ed. Elsevier; 2010.

   -  Villar L. Endocrinologia Clínica. 6ª ed. Grupo Gen - Guanabara Koogan; 2016.

   -  Nogueira A Impellizzeri et al. Endocrinologia para o clínico. 1ª ed. CoopMed; 2016.

   -  Terris D, Duke W. Thyroid and Parathyroid Diseases. 2nd edition. Thieme; 2016.

Authors

Larissa Gonçalves Rezende, 3th year medical student at Universidade Federal de Minas Gerais.

E-mail: larissarezendeg[at]gmail.com

Supervisors

Professor Beatriz Santana Soares Rocha, adjunct professor of the Department of Internal Medicine at the Medical School of Universidade Federal de Minas Gerais and coordinator of the Endocrinology and Metabology Medical Residency Program - HC-UFMG.

E-mail: beatrizssrocha[at]gmail.com

 

Luciana Cristian Coelho Garcia, resident physician in Endocrinology and Metabology - HC-UFMG.

E-mail: lcristiancoelho[at]gmail.com

 

Professor Pedro Augusto Lopes Tito, adjunct professor of the Department of Anatomy and Imaging at Medical School of Universidade Federal de Minas Gerais.

E-mail: peralarep[at]gmail.com

Reviewers

Jhonatas PereiraMateus Nardelli, Gabriella Shiomatsu, Letícia Melo, Luiz Gustavo Ferreira, Profa. Dra. Viviane Santuri Parisotto Marino, Prof. Júlio Guerra Domingues.

Translated by

Ana Luísa Melgaço Almeida, 6th year medical student at Universidade Federal de Minas Gerais.

E-mail: analuisamelgaco[at]outook.com

Test question

COMISSÃO ESTADUAL DE RESIDÊNCIA MÉDICA DO AMAZONAS – AM 2016

In primary hyperparathyroidism, we may find:

a) Augmented levels of calcium and PTH.

25%

b) Augmented levels of PTH and diminished levels of serum calcium.

25%

c) Diminished levels of PTH and calcium.

25%

d) Diminished levels of PTH and augmented levels of serum calcium.

25%

e)

25%
   

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