A preoperative parathyroid scan is important for the total removal of the transplanted parathyroid tissue in recurrent secondary hyperthyroidism: A case report and literature review

Abstract

Rationale: Secondary hyperparathyroidism was one of mineral and bone disorders owing to chronic kidney disease. Patients who suffer from secondary hyperparathyroidism would receive medical treatment or parathyroidectomy with or without autotransplantation (AT). However, some patients receiving parathyroidectomy with AT have recurrent hyperparathyroidism, which impacts their lives. Patients with recurrent hyperparathyroidism may present persistent hypercalcemia and hyperphosphatemia, which would cause cardiovascular disease, like atherosclerosis.

Patient concerns: A 63-year-old female of Asian descent with chronic kidney disease who suffered from recurrent hyperparathyroidism for twice. The patient underwent parathyroidectomy with AT in the left thigh when secondary hyperparathyroidism happened. After 3 months, recurrent hyperparathyroidism happened.

Diagnosis: The patient was diagnosed with recurrent hyperparathyroidism due to chronic kidney disease with hyperparathyroidism status post parathyroidectomy with AT in the left thigh. Our patient also suffered from mineral and bone disorder.

Intervention: Two parathyroid adenoma in the left thigh were found. However, one of them was too small to found in the operation. Therefore, autograftectomy of the large one was performed. However, hyperparathyroidism happened again. This time, the autograftectomy was performed under dual phase Tc-99m MIBI (99m Tc-methoxy isobutyl isonitrile) parathyroid scintigraphy and it succeeded.

Outcomes: After secondary autograftectomy, the value of intact parathyroid hormone was surveyed immediately and dropped by two-third followed by gradual reduction in the following weeks. The calcemia and phosphatemia were back to normal gradually.

Lessons: In our case, importance of scintigraphy in the parathyroidectomy was confirmed.

Figure 1.

The preoperative sonography before first autograftectomy showed 2 hypoechoic masses. The larger one (1.7 cm × 0.4 cm, arrow head) and the smaller one (0.6 × 0.4 cm, arrow) at adjacent area.

Figure 2.

The intraoperative sonography during the first autograftectomy showed only the larger parathyroid mass (1.7 7cm × 0.37cm, arrow head) and was removed, but the smaller one was not definitely identified under sonography during operation and was left behind with the idea that even if the small remnant tissue not being removed might not be harmful afterwards. (v: vessel).

Figure 3.

A. 2 hypoechoic lesions (1.75 cm × 0.57 cm, arrow head) respectively were noted on the left medial thigh in intraoperative sonography before second operation. Figure 3B. The dual phase Tc-99m MIBI parathyroid scintigraphy showed abnormal uptake on left thigh before second operation. (square frame).

Figure 4.

SPECT showed accurate position abnormal uptake at subcutaneous layer at lower medial aspect of left thigh. (square frame).

Figure 5.

Intraoperative ultrasonography at secondary operation showed a hypoechoic lesion (2 cm × 1.4 cm × 0.6 cm, arrow), which was 3 times of initial size. (figure 1. Arrow).

Figure 6.

After follow-up 10 month, there was only scar at the operation site. No other residual parathyroid tissue seen in sonography.