Radiologic detection of parathyroid adenoma

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A 58-year-old white woman was seen at the Cleveland Clinic with bone pain and muscle cramps, polydipsia, and generalized weakness and malaise. She had a history of renal failure and urolithiasis. At another institution, she was found to have hypercalcemia and a lytic defect in the right iliac wing. Despite two surgical neck explorations in which three normal parathyroid glands were removed and no abnormalities were found, the symptoms persisted and she was referred to the Cleveland Clinic.

At another hospital, prior to admission to the Cleveland Clinic, collections of blood from veins draining the upper mediastinum and neck regions had been obtained by selective catheterization. Elevated levels of parathormone were detected in the serum from the veins draining the region of the right thymus.

On admission to the Cleveland Clinic, the blood urea nitrogen (BUN) level was 32 mg/dl; creatinine, 2.9 mg/dl; calcium, 12.6 mg/dl; phosphorus, 3.8 mg/dl; alkaline phosphatase, 2000 units/L; and hemoglobin, 10.5 g/dl. Because of the elevated parathormone levels in the veins from the region of the right thymus, the right thyroid lobe and right side of the thymus were excised. No parathyroid tissue or tumor was identified.


1. In the further care of this patient, what would you recommend? What region should be evaluated and by what method?

2. Has this patient had the most effective evaluation of her problem?

After consultation with the Department of Diagnostic Radiology, a high-resolution CT scan of the mediastinum was obtained. A mediastinal mass was identified just anterior . . .