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Weekly Chest CasesArchive of Old Cases

Case No : 1231 Date 2021-05-25

  • Courtesy of Cherry Kim / Korea university Ansan hospital
  • Age/Sex 75 / F
  • Chief ComplaintGeneral weakness (1 week ago)
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Ectopic parathyroid adenoma
Radiologic Findings
Figs. 1 and 2. A 5.5-cm ovoid heterogeneously enhancing mass lesion in the right paratracheal area, in the inferior aspect of the right thyroid gland, without definite continuity.
Fig. 3. Technetium-99m (Tc-99m) MIBI scans (taken at 20 min and 2 h). The Tc-99m MIBI image taken at 20 min shows a diffusely enlarged thyroid gland. A large residual uptake in the right upper paratracheal area is seen in the 2-h image.
Brief Review
1. Incidence: 20%–25% of all parathyroid adenomas
2. Inferior parathyroid gland (more common)
- Carotid bifurcation (parapharyngeal, carotid space)–thymus (anterior mediastinum)
3. Superior parathyroid gland (less common)
- Pseudoectopia (m/c): enlarged gland falling caudally and posteriorly in the tracheoesophageal groove → posterior mediastinal location
Rare: retropharyngeal space or intrathyroid
4. Imaging modality for the parathyroid gland
- Imaging for primary hyperparathyroidism: there is no universally accepted algorithm for imaging the parathyroid glands. It depends on surgeon preference and radiology practice
- Characteristic morphology
Oval, round, or tubular lesion with smooth or slightly lobulated margins
Cystic degeneration or hemorrhage: common
“Polar vessel sign”
- Characteristic vascular morphologic features in the arterial phase
Enlarged tortuous feeding arteries/draining veins course around the periphery
- Characteristic enhancement patterns
Peak enhancement in the arterial phase, diminishing or washout in the venous phase

* Commonly used imaging modalities
Ultrasound (US) and nuclear medicine: conventional first-line modality
US: limited utility for mediastinal and retroesophageal lesions
Nuclear medicine:
Scintigraphy: dual-phase single isotope (technetium-99m [99mTc]-sestamibi) or single-phase dual isotope (99mTc-sestamibi)
Single-photon emission computed tomography/computed tomography (CT): improves lesion localization
CT: multiphase four-dimensional CT (three-phase) shows comparable sensitivity/specificity to US/nuclear medicine
5. Ectopic mediastinal parathyroid adenoma
- m/c site of ectopic parathyroid adenoma
- Prevascular mediastinal (around the thymus) or paraesophageal location
Hyperparathyroidism + prevascular/paraesophageal mass: ectopic parathyroid adenoma should be suspected

* Differential diagnosis
Mediastinal goiter – connects with the thyroid gland
Thymic lesion
Lymphoid lesion (lymphoma, metastatic lymphadenopathy)
Please refer to
Case 1036, Case 920, Case 526,
References
Hoang JK, Sung WK, Bahl M, Phillips CD. How to perform parathyroid 4D CT: tips and traps for technique and interpretation. Radiology 2014;270(1):15–24.
Roy M, Mazeh H, Chen H, Sippel RS. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg 2013;37:102-6.
Juanpere S, Cañete N, Ortuño P, Martínez S, Sanchez G, Bernado L. A diagnostic approach to the mediastinal masses. Insights Imaging 2013;4(1):29–52.
Carter BW, Benveniste MF, Madan R, et al. ITMIG Classification of Mediastinal Compartments and Multidisciplinary Approach to Mediastinal Masses. Radiographics 2017; 37:413.
Keywords

No. of Applicants : 90

▶ Correct Answer : 52/90,  57.8%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Showa General Hospital , Japan MASAFUMI KAIUME
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
  • - Other , Korea (South) HYEJIN YANG
  • - , Saudi Arabia ABDULLAH ALOTAIBI
  • - , Korea (South) HYEYOUNG CHOI
  • - Chonbuk National University Hospital , Korea (South) MINGI SHIN
  • - Inje University Haeundae Paik Hospital , Korea (South) HYUNGIN PARK
  • - , Italy PAOLO BALDASSARI
  • - , India DIWAKAR C
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
  • - Chungbuk National University Hospital , Korea (South) JIYUN KANG
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Seoul National University Bundang Hospital , Korea (South) SUNG HYUN YOON
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Kyeongpook National University Hospital , Korea (South) HYEONJUN JANG
  • - Gifu University Hospital , Japan Yo Kaneko
  • - VDC, HYDERABAD , India KARTHIK RAYASAM
  • - , Japan KANAE TAKAHASHI
  • - McGill , Canada MUTAZ ADNAN KHAIRO
  • - Samsung Medical Center , Korea (South) KYOWON GU
  • - Soonchunhyang University Hospital Bucheon , Korea (South) SEONGHWAN BYUN
  • - Mallinckrodt Institute of Radiology , United States NAGANATHAN MANI
  • - Other , Korea (South) MINSU KIM
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - CHU Lille , France PAUL LEBERT
  • - Seoul Veterans Hospital , Korea (South) JANG SEONG WON
  • - Chungbuk National University Hospital , Korea (South) PARK JUN HYEON
  • - , Saudi Arabia RAWAN AHMED ALJEFRI
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Other , Korea (South) KYU-CHONG LEE
  • - Kyoto University Hospital , Japan SATOSHI IKEDA
  • - Nishida Hospital , Japan SHOJI OKUDA
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - , Japan KAZUMA TERAUCHI
  • - Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
  • - National Center for Global Health and Medicine , Japan TOMOKI IMOKAWA
  • - Private sector , Greece VASILIOS TZILAS
  • - , Japan YUKI HAYASHI
  • - Chonnam National University Hwasun Hospital , Korea (South) WONGI JEONG
  • - , Korea (South) JIHYUN KIM
  • - Kyoto university , Japan AKIHIKO SAKATA
▶ Correct Answer as Differential Diagnosis : 11/90,  12.2%
  • - Korea University Guro Hospital , Korea (South) LEE SEOKYOUNG
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - NIMS, HYDERABAD , India BHASKAR K
  • - , Japan CHIAKI SATO
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - HHS , Canada S LEE
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
▶ Semi-Correct Answer : 3/90,  3.3%
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Chonbuk National University Hospital , Korea (South) YOUNG JU SONG
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Current Editor : Sang Young Oh, M.D., Ph.D Email : sangyoung.oh@gmail.com

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