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Abstract
Persistent or recurrent primary hyperparathyroidism after initial parathyroid surgery occurs at rates of 1.5~10%. A single missed parathyroid adenoma accounts for the majority of persistent hyperparathyroidism, whereas metachronous parathyroid adenoma is a rare cause of recurrent hypercalcemia.
We report a case of a 39-year-old female who presented with recurrent pancreatitis. She had symptoms of hyperparathyroidism such as hypercalcemia, hypophosphatemia, hypercalciuria, nephrocalcinosis, and osteoporosis. She had a 2-cm firm neck mass under the right submandibular area. She was diagnosed with primary hyperparathyroidism 22 years ago. At that time, the right upper and lower parathyroid glands were removed after exploration of all parathyroid glands, and a right upper parathyroid adenoma was diagnosed. Now, she had a second surgery to remove the right submandibular mass with intraoperative PTH monitoring, which was diagnosed as a parathyroid adenoma in an ectopic supernumerary parathyroid gland. Because of hungry bone syndrome, she received calcium carbonate replacement therapy and has no evidence of recurrence. Here, we report a recurrent parathyroid adenoma in the undescended, supernumerary parathyroid gland after a long interval from the initial surgery.
Figures and Tables
Fig. 1
A. There is a diffuse parenchymal swelling with pseudocyst and peripancreatic infiltration in the tail of pancreas which is compatible with acute pancreatitis. B. In the kidney, bilateral renal medullary calcinosis is noted.
Fig. 2
A. There is a 2.2 × 1.2 cm sized circumscribed oval shaped multiseptated cystic mass in right submandibular area in the cervical ultrasound. B. About 2.6 cm measured ovoid solid mass in right submandibular space, attached to inferior portion of right submandibular gland is observed in the neck CT scan. C. The 20-minute image shows Tc-99m sestamibi uptake in the thyroid and a nodular mass in the right upper neck. In the 3-hour delayed image, the thyroid glands show less uptake, whereas the right upper neck mass shows more intense uptake.
Fig. 3
Microscopy of parathyroid adenoma shows partial hemorrhagic infarction. (H&E. ×2, ×40, ×100, ×400, clockwise). A. The tumor does not have well defined connective tissue capsule. Left upper portion shows massive hemorrhagic infarction. Lower cellular portion shows multinodular growth pattern. B. There is no vascular invasion, perineural space invasion or capsular penetration with growth into adjacent tissues, which are differential point from parathyroid carcinoma. C. The tumor shows hemorrhagic infarction. D. The chief cells are predominant and arranged in acinar pattern. The cytoplasm is either faintly eosinophilic or vacuolated. Nuclei are round, and have finely dense chromatin and inconspicuous nucleoli which corresponds to parathyroid adenoma.
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