Multiple endocrine neoplasia type 1 with anterior mediastinal parathyroid adenoma: successful localization using Tc-99m sestamibi SPECT/CT

Association of primary hyperparathyroidism with pituitary adenoma and management issues

The co-occurrence of primary hyperparathyroidism (PHPT) and pituitary adenomas (PAs) is often indicative of underlying genetic syndromes such as Multiple Endocrine Neoplasia type 1 (MEN1) and, less commonly, MEN4. Although both conditions can occur sporadically, their simultaneous presence warrants evaluation for genetic mutations, with MEN1 mutations being the most frequent cause. The management of concurrent PHPT and PAs, especially in MEN1 patients, presents unique challenges. Management complexities arise from the syndromic nature, involving both surgical and medical interventions tailored to each condition. PHPT often manifests earlier and more aggressively in MEN1, requiring surgical intervention. However, recurrence rates remain high due to multiglandular involvement. Pituitary adenomas in MEN1 are primarily prolactinomas, and treatment with dopamine agonists results in significant tumour control in most cases. Overall, PAs associated with MEN1 are generally responsive to medical therapy, but careful long-term monitoring is essential. The utility of genetic screening cannot be overstated, as it aids in early detection, risk stratification, and management of both the index case and affected family members by cascade screening. A multidisciplinary approach is crucial for optimizing outcomes, with ongoing surveillance to manage recurrence and associated complications. In summary, the co-occurrence of PHPT and PAs, particularly in the context of MEN1, necessitates an integrated management strategy. Genetic testing is key in confirming diagnosis and guiding treatment, while surgical and medical interventions should be tailored to the extent and nature of glandular involvement. Close monitoring for recurrence and proactive family screening are essential components of long-term care.

Giant Parathyroid Adenoma of the Posterior Mediastinum

Ectopic parathyroid adenoma is a rare pathology. We present a clinical case of a giant ectopic parathyroid adenoma (PA) in an unusual location, which brought significant diagnostical and therapeutical challenges. The tumour in the mediastinum was found incidentally on chest computed tomography (CT). A biopsy was conducted, and histological examination revealed a well-differentiated neuroendocrine tumour. The tumour was excised via right thoracotomy. The final histological examination revealed a parathyroid adenoma, which was unexpected for our team. After three years of observation, there is no evidence of tumour recurrence.

GIANT MEDIASTINAL PARATHYROID ADENOMAS AND MULTIPLE ENDOCRINE NEOPLASIA TYPE 1: A DIAGNOSTIC CONUNDRUM

CONTEXT

Giant parathyroid adenoma (GPA) is a rare entity that is rarer with Multiple endocrine neoplasia type 1 (MEN1) syndrome.

OBJECTIVES

Describe the clinical presentation, diagnostic difficulties, and management strategy for GPA in MEN1.

METHODS

We searched Pubmed, SCOPUS and EMBASE for GPA in MEN1 for GPA in association with MEN1. Hereby, we describe index case of largest ever reported GPA.

RESULTS

We identified 7 cases of GPA reported till date in association with MEN1. The mean adenoma weight was 7.1 gram. The index case is largest-ever reported GPA (weight 97 gram) in MEN1 presenting with compressive symptoms and mediastinal mass. Incidentally, she was found to have hypercalcemia with increased parathyroid hormone, suggesting primary hyperparathyroidism. The possibilities of an ectopic parathyroid tumor and thymic carcinoid were considered. She also had acromegaloid features, and was found to have a sellar tumor. Subsequently, MENIN gene mutation was identified confirming MEN1 syndrome. Patient underwent trans-sternal excision of the mass weighing 97 grams and confirmed as parathyroid adenoma on histopathologic examination.

CONCLUSION

Despite rarity of ectopic mediastinal parathyroid tumors, calcium profile should be considered as part of work-up of considering varied etiologies of anterior mediastinal mass.

Primary hyperparathyroidism associated with MEN 1: Experience in 71 cases

INTRODUCTION

Primary hyperparathyroidism (pHPT) in MEN 1 is characterized by multiglandular disease and early involvement of parathyroid glands at different times. Persistence and recurrence range from 25%-35%. The purpose was: a) to describe the experience and the treatment of patients with pHPT in MEN 1; b) to analyze the variables related with clinical presentation and recurrence.

METHOD

A total of 97 patients with MEN 1 were diagnosed in a tertiary hospital. A retrospective analysis was made in patients with pHPT (n=71).

STUDY VARIABLES

age at diagnosis, mutation, clinical presentation, laboratory tests, surgical technique, and recurrence of HPT.

RESULTS

Mean age was 38 years, and 50 patients were asymptomatic. The surgical technique was: subtotal parathyroidectomy (n=55), resection of three glands (n=7), and resection of less glands (n=9). Transcervical thymectomy was performed in 53 patients. Mean follow-up was 102.9 months. There were 21 recurrences, There were correlations between age at diagnosis and serum calcium levels with the presence of symptoms (P<.0001). There were also correlations between recurrence and surgical technique (P<.03), non-association with thymectomy (P<.0001), and follow-up time (P<.03).

CONCLUSION

Performing genetic and clinical screening allows us to make a diagnosis in the asymptomatic period and to provide early treatment for HPT in MEN 1. The recurrence rate is high, and follow-up time and the surgical technique used are risk factors for recurrence.