Piggott R P, Waters P S, Ashraf J, Colesky F, Kerin M J
Discipline of Surgery, School of Medicine, National University of Ireland, Galway, Ireland.
Int J Surg Case Rep. 2013;4(10):911-3. doi: 10.1016/j.ijscr.2013.07.016. Epub 2013 Aug 3.
Primary hyperparathyroidism is a common endocrine disorder, with an incidence of 21.6 per 100,000 person-years. Asymptomatic elevated serum calcium levels on routine biochemical investigations accounts for 80% of newly diagnosed primary hyperparathyroidism. Solitary adenoma is the commonest cause of primary hyperparathyroidism and can be treated by excision of a single gland.
We present a case of primary hyperparathyroidism in a 74-year-old female was referred to our surgery endocrine outpatients for assessment of a persistently elevated calcium level, lower abdominal pain and constipation. Biochemical analysis revealed corrected serum calcium of 3.13mmol/L (reference range 2.17-2.51mmol/L) and an intact parathyroid hormone level (iPTH) of 488.9ng/L (reference range 15-65ng/L). Sestamibi scan localised a persistent increased area of activity inferior to the lower pole of the left lobe of thyroid gland.
The patient underwent a minimally invasive parathyroidectomy using a 3cm incision with intra-op radionucliotide localisation. At surgery a single large parathyroid gland measuring 5.5cm was excised without complication. Grossly the parathyroid gland was an encapsulated tan mass measuring 5.5cm×2.5cm×2cm and weight 13g and histological assessment revealed a water-clear cell (WCC) adenoma. She made an uneventful post op recovery with normalisation of her serum calcium.
WCC adenomas have a "low endocrinological activity" in which serum calcium levels do not elevate until the adenoma has reached considerable size. Our case supports this hypothesis and aids to the understanding of these rare tumours.
原发性甲状旁腺功能亢进是一种常见的内分泌疾病，发病率为每10万人年21.6例。在新诊断的原发性甲状旁腺功能亢进中，80%是在常规生化检查时发现无症状的血清钙水平升高。孤立性腺瘤是原发性甲状旁腺功能亢进最常见的病因，可通过切除单个腺体进行治疗。
我们报告一例74岁女性原发性甲状旁腺功能亢进病例，该患者因持续升高的钙水平、下腹部疼痛和便秘被转诊至我们外科内分泌门诊。生化分析显示校正血清钙为3.13mmol/L（参考范围2.17 - 2.51mmol/L），完整甲状旁腺激素水平（iPTH）为488.9ng/L（参考范围15 - 65ng/L）。甲氧基异丁基异腈扫描显示甲状腺左叶下极下方有一个持续活动增加的区域。
患者接受了微创甲状旁腺切除术，采用3cm切口并在术中进行放射性核素定位。手术中切除了一个大小为5.5cm的单个大甲状旁腺，无并发症。大体上，甲状旁腺是一个包膜完整的棕褐色肿块，大小为5.5cm×2.5cm×2cm，重13g，组织学评估显示为水样透明细胞（WCC）腺瘤。她术后恢复顺利，血清钙恢复正常。
WCC腺瘤具有“低内分泌活性”，即直到腺瘤达到相当大的尺寸时血清钙水平才会升高。我们这例病例支持这一假说，有助于对这些罕见肿瘤的理解。
