Case 1, 69/M

Clinical Presentation
Mood swings, depression, memory loss -1 yr
Polyuria, Weight loss: 8 kg in 1 year
On Tt for hyperkalemia, high s-creatinine
Past H/o
UB calculus- removal 15 yrs back
# rt clavicle, left femur
No thyroid or other nodular neck swellings
No bony swellings, fractures, muscle weakness
S-calcium
T: 11.2 mg% (8.5-10.8)
I: 5.3 mg% (4.5-5.3)
S-iP 2.3 (2.5-4.5)
S-ALP 108 (<80IU)
S-iPTH 90 pg/ml (14-72)
USG neck- ovoid 1.5 cm
hypoechoic lesion postr to rt
thyroid lobe

BMD T score Z score
L1-14 +1.2 +2.7
Right hip -1.8 -1.1
Forearm -3.1 -2.0
Case 1, 69/M
Investigations
MIBI scan
adenoma upper pole
rt thyroid lobe
Rt Focused PTx under cervical block
IOPTH monitoring
Case 1, 69/M
Operative Management
Rt sup PT adenoma: deep in T-E groove near sup pole,
2.2x1.5x1.2 cms, 900 mgs, sent for frozen
Rt inf PT- slightly enlarged, 1x0.7x0.6 cm, 100 mgs excised for
frozen, HPE
Rt Supr PT tumor Rt inferior PT
86.7
21.1
23.7
29.6
0
10
20
30
40
50
60
70
80
90
100
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5

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1
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IOPTH

Histopathology for discussion
Gross specimen
Received two specimens

Right superior parathyroid measuring
2.1x1.5x1.1cm and weighing 900mgs.

Right inferior parathyroid measuring
1.0x0.5x0.3cm and weighing 100mgs.
Intraoperative histology
Right superior parathyroid
Encapsulated nodule
Predominantly chief cells
Rim of compressed normal parathyroid tissue

Right superior parathyroid
Capsule

Right superior parathyroid
Right inferior
parathyroid
(Intraoperative)
Normal
parathyroid

Chief cells
Oxyphil cells
Adipose tissue
Right inferior parathyroid
(Intraoperative)
Definitive Histology -right
inferior parathyroid
Large circumscribed oxyphil nodule
Predominantly oxyphil cells admixed with few
chief cells
Peripheral portion shows parathyroid
parenchymal cells admixed with adipose
tissue

Oxyphil nodule
Right inferior parathyroid
Definitive histology

Oxyphil cells
Right inferior parathyroid
Definitive histology

Intra-operative opinion
Right superior parathyroid: Parathyroid adenoma
Right inferior parathyroid: Normal

Final conclusion
Right superior parathyroid: Parathyroid adenoma

Right inferior parathyroid: Normal parathyroid gland with
Oxyphil nodule*
*Age related
Adenoma Multigland
Hyperplasia
Carcinoma
Red brown nodule
Smooth
circumscribed
Encapsulated
All glands enlarged
equally or nonequally
Lower usually larger

Dense fibrous reaction
Adherent or infiltrating
Parathyroid chief
cells
Delicate capillary
network
Stromal fat absent
Rim of parathyroid

Diffuse chief cells
Minimal to no fat
Rare oxyphils
Nodular or
psudoadenomatous
No rim usually
Trabecular arrangement
Dense fibrous bands
Spindle shape
Mitotic figures
Capsular invasion
Vessel invasion
Oxyphil nodule
Oxyphil cells increase with age
Singly or in small clusters
Child to adulthood
Nodular conglomerates
May acquire a follicular pattern
Intraluminal amyloid can be seen


Symptoms relieved, Free from complications
Normocalcemic, on oral Calcium & vit D
supplements
Lowering s- creatinine, normal s-PTH

Case 1, 69/M
Post-op Course : 3 months Fu