Recurrent renal hyperparathyroidism due to parathyromatosis

Abstract

Parathyromatosis is the most severe type of recurrent secondary hyperparathyroidism (SHPT) after parathyroidectomy (PTX) in haemodialysis patients. It is difficult to completely remove all foci of parathyroid tissue and neck re-explorations are often required. Here, we report for the first time a case of recurrent SHPT due to parathyromatosis treated by radio-guided PTX. A haemodialysed 48-year-old woman with recurrent SHPT due to parathyromatosis was treated by radio-guided PTX. Preoperatively Ultrasonography, (99)Tc-SestaMIBI scintigraphy and magnetic resonances of the neck and thorax were performed. The preoperative imaging techniques detected four parathyroid nodules, while intraoperative gamma probe identified six nodules (three in atypical site). No frozen sections were performed during surgery. Post-operative intact parathyroid hormone levels were stabilized in the range 300-500 pg/mL during the 26 month follow-up by means of cinacalcet and paricalcitol therapy. In cases of parathyromatosis, the preoperative imaging techniques are inadequate, while intraoperative gamma probe is useful to detect the parathyroid tissue and allows a more extensive cytoreduction because it ensures the removal of undetectable and ectopic parathyroid foci. The operative time is reduced and frozen sections are unnecessary. However, the radio-guided PTX do not rule out parathyromatosis recurrence and complementary medical treatment is appropriate.

Keywords: haemodialysis; parathyromatosis; radio-guided parathyroidectomy; secondary hyperparathyroidism.

Fig. 1.

A PTG was detected by gamma probe in the upper third of the right neck within subcutaneous tissue below the platysma muscle. Histology showed benign parathyroid nodule surrounded by muscle tissue.

Fig. 2.

Upper panel. Dual phase ⁹⁹Tc SestaMIBI scintigraphy: four areas of elevated uptake and slow wash out of the tracer in the tardive phase suggestive of the presence of parathyroid tissue are shown. Lower panel. Parathyroid glands (PTG) removed during surgical exploration: intact PTG (left), longitudinal section (right). A PTG (Number 1) was detected within subcutaneous tissue below the platysma muscle corresponding to the right upper third of the neck; two nodules of soft, yellow–white parathyroid tissue are scattered around the left thyroid lobe (Numbers 2 and 3); one PTG (Number 5) over median cervical line; a PTG (Number 4) was detected within the left sternocleidomastoideus muscle. Finally, a PTG (Number 6), macroscopically non-visible, was detected by gamma probe and confirmed by histology of the thyroid gland. The PTG 5 and 6 were not detected by preoperative imaging techniques but were identified by intraoperative gamma probe.