A 63-year-old man was referred to urology in view of a left renal calculus. He was found to have a raised calcium (Ca corrected 2.87 mmol/l) and a raised parathyroid hormone (PTH 140 ng/l). He had a chest x-ray which showed widening of the superior mediastinum on the right (), with an ovoid right paratracheal mass indenting the trachea. A CT scan of the chest showed a large well-defined mass with central low attenuation in the right paratracheal region (). It extended from the thyroid down to the level of carina displacing the trachea to the left without any compression. There was no lymphadenopathy. He was referred to a respiratory physician for consideration of surgical biopsy.
Chest x-ray showing widening of the mediastinum on the right side.
CT scan of the chest showing a large superior mediastinal mass.
A subsequent ultrasound scan of the neck identified the mediastinal mass, the upper part being deep to the right lobe of the thyroid gland. It was solid with some areas of cystic changes and prominent vascularity. The radiological differential included teratoma and a thymoma. A CT guided biopsy showed a cellular specimen rich in neutrophils, polymorphs and lymphocytes with uniform appearance. This was suggestive of an endocrine or neuroendocrine tumour. A tracheal core biopsy showed small regular islands of cells with bland circular nuclei and a moderate amount of eosinophilic cytoplasm. The tumour marked strongly with chromogranin and very weakly with synaptophysin, suggesting parathyroid origin.
He was then referred for an endocrine opinion. He had no abdominal pain or constipation but has had painful ribs for few years. There was no past or family history of note. He had a bone scan which showed osteoporosis of left forearm (T score –3.0) and osteopenia of the hip (T score –1.1). His 24 h urinary calcium was normal (3.5 mmol/l) as was serum vitamin D level (40 nmol/l). 99Tc Sestamibi scintigraphy scanning also confirmed a large parathyroid adenoma with central necrosis.
He underwent surgery through a standard cervical approach, and the histology was consistent with a parathyroid adenoma. His latest calcium remains normal (2.24 mmol/l) as is the PTH level (68 ng/l).