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Table of Contents
Year : 2016  |  Volume : 20  |  Issue : 6  |  Page : 878-879

Synchronous parathyroid adenoma and papillary thyroid cancer detected on 99mTc-sestamibi scintigraphy

1 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
3 Department of Medicine, Endocrinology Unit, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Date of Web Publication24-Oct-2016

Correspondence Address:
Nishikant A Damle
Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2230-8210.192915

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How to cite this article:
Taywade SK, Damle NA, Tripathi M, Agarwal S, Aggarwal S. Synchronous parathyroid adenoma and papillary thyroid cancer detected on 99mTc-sestamibi scintigraphy. Indian J Endocr Metab 2016;20:878-9

How to cite this URL:
Taywade SK, Damle NA, Tripathi M, Agarwal S, Aggarwal S. Synchronous parathyroid adenoma and papillary thyroid cancer detected on 99mTc-sestamibi scintigraphy. Indian J Endocr Metab [serial online] 2016 [cited 2021 Jul 25];20:878-9. Available from: https://www.ijem.in/text.asp?2016/20/6/878/192915


Medullary thyroid cancer and concomitant primary hyperparathyroidism is common in multiple endocrine neoplasia-2A.[1] Similar origin of both cell types could be one of the explanations. However, concomitant nonmedullary thyroid cancer and Primary Hyperparathyroidism (PHP) is rare.[2] According to some, this is just a coincidental finding and some authors relate this to radiation exposure in childhood or adolescence, increased calcium, epithelial growth factors and insulin-like growth factor. Moreover, this association has been studied mostly based on operative findings and postoperative histopathology reports. Few case reports and interesting images have shown evidence of concomitant papillary thyroid cancer and PHP on radionuclide scintigraphy, not much is explained in the literature about this rare association on preoperative evaluation.[3],[4],[5],[6]

Definite treatment for parathyroid adenoma is surgical removal. Hence, the accurate preoperative localization of adenoma is utmost important. This has a proven advantage in not only reducing the intraoperative time for exploration but also increasing the operative success rate and ultimately preventing unnecessary intraoperative intervention. Over many years, various functional and anatomical and functional imaging modalities have been evolved for preoperative localization of parathyroid adenoma. With advances in newer modalities, especially like Tc-99m-sestamibi single-photon emission computed tomography (SPECT/CT), 4DCT, and F-18 fluorocholine positron emission tomography/CT, spatial resolution and subsequently detection smaller parathyroid adenoma along with detection of incidental findings has improved significantly.

In the present case, 99m Tc-sestaMIBI SPECT/CT [Figure 1]a, [Figure 1]b and [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f demonstrated left inferior parathyroid adenoma with another mass lesion in the left lobe of thyroid, a hypodense lesion in the right lobe of thyroid and left level IV cervical lymph nodes with mild tracer uptake. With these findings, possibilities of parathyroid adenoma and concurrent thyroid carcinoma with cervical lymph nodal metastasis or metastatic parathyroid carcinoma with concurrent thyroid nodule were raised. To assess bony involvement by hyperparathyroidism, the patient also underwent Tc-99m-methylene diphosphonate bone scan [Figure 1]c and [Figure 1]d. It demonstrated features of metabolic superscan. Fine needle aspiration cytology from left cervical lymph node revealed papillary carcinoma of the thyroid. Further, patient underwent a complex surgery of removal of parathyroid adenoma along with total thyroidectomy and left neck dissection. Final histopathology revealed parathyroid adenoma, synchronous left lobe papillary thyroid carcinoma with ipsilateral cervical lymph node metastasis; however, right lobe of thyroid did not demonstrate any malignant features.
Figure 1: (a) Tc-99m-sestamibi planar images of neck and chest at 15 min showed diffuse uptake in thyroid, focal increased uptake in the region of left lobe of thyroid (thick arrow) and faint uptake in the left lower cervical region lateral to the thyroid (thin arrow), (b) there was washout of uptake from thyroid and persistent intense uptake inferior to left lobe of thyroid at 50 min. (c and d) Tc-99m-methylene diphosphonate bone scan anterior and posterior views showing increased bone to soft tissue ratio with increased tracer uptake in calvaria, bared sign, and nonvisualization of kidneys consistent with superscan

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Figure 2: (a-f) Transaxial single-photon emission computed tomography Tc-99m-sestamibi images showed soft tissue density lesion just below the left lobe of thyroid with intense radiotracer uptake (thick arrow), irregular mass in the left lobe of thyroid (outlined arrow) with no tracer radiotracer uptake, hypodense lesion with mild uptake in the right lobe of thyroid (dotted arrow) and rounded left level IV cervical lymph nodes with mild tracer uptake (thin arrow)

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Thus, this letter emphasizes the usefulness of Tc-99m-sestamibi scintigraphy in the evaluation of concomitant thyroid pathologies in a patient with parathyroid adenoma and also illustrates the importance of incidental findings in thyroid and neck which otherwise could be overlooked.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Beus KS, Stack BC Jr. Synchronous thyroid pathology in patients presenting with primary hyperparathyroidism. Am J Otolaryngol 2004;25:308-12.  Back to cited text no. 1
Montenegro FL, Smith RB, Castro IV, Tavares MR, Cordeiro AC, Ferraz AR. Association of papillary thyroid carcinoma and hyperparathyroidism. Rev Col Bras Cir 2005;32:115-9.  Back to cited text no. 2
Leitha T, Staudenherz A. Concomitant hyperparathyroidism and nonmedullary thyroid cancer, with a review of the literature. Clin Nucl Med 2003;28:113-7.  Back to cited text no. 3
Onkendi EO, Richards ML, Thompson GB, Farley DR, Peller PJ, Grant CS. Thyroid cancer detection with dual-isotope parathyroid scintigraphy in primary hyperparathyroidism. Ann Surg Oncol 2012;19:1446-52.  Back to cited text no. 4
Spieth ME, Mulligan GM, Nguyen T, Kasner DL. Incidental thyroid carcinoma on parathyroid imaging. Clin Nucl Med 2002;27:658-9.  Back to cited text no. 5
Javadi H, Jallalat S, Farrokhi S, Semnani S, Mogharrabi M, Riazi A, et al. Concurrent papillary thyroid cancer and parathyroid adenoma as a rare condition: A case report. Nucl Med Rev Cent East Eur 2012;15:153-5.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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