A Rare Presentation of Giant Parathyroid Adenoma in the Context of Chronic Kidney Disease: A Case Report

A Rare Presentation of Giant Parathyroid Adenoma in the Context of Chronic Kidney Disease: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Rare Presentation of Giant Parathyroid Adenoma in the Context of Chronic Kidney Disease: A Case Report Eduarda Maria Magalhães Gonçalves, Paulo J. Sousa, José Pedro Pinto, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6197397/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Primary hyperparathyroidism (PHPT), a common endocrine disorder, disrupts calcium homeostasis and frequently arises from a parathyroid adenoma. In rare instances, giant parathyroid adenomas (GPAs), defined as those weighing more than 3.5 grams, may develop, posing diagnostic challenges, particularly in distinguishing them from parathyroid carcinoma (PC). A 74-year-old female patient with chronic kidney disease (CKD) of undetermined origin was referred for evaluation of suspected PHPT. Laboratory investigations revealed elevated serum calcium and parathyroid hormone (PTH) levels. Scintigraphy and ultrasonography suggested the presence of a GPA, leading to parathyroidectomy. Histopathological analysis of the resected adenoma confirmed a weight of 12 grams. While PHPT is often associated with smaller adenomas and may be asymptomatic, GPAs typically manifest with clinical symptoms. Imaging modalities, such as ultrasound and scintigraphy, are crucial in differentiating GPAs from PCs. These cases are uncommon and necessitate specialized management strategies. A comprehensive preoperative assessment, including appropriate imaging, is vital; fine-needle aspiration biopsy has low sensitivity. In cases of GPA, the surgical team must be prepared for potential conversion to radical oncological surgery to ensure complete resection. Figures Figure 1 Figure 2 Figure 3 Introduction Primary hyperparathyroidism is a prevalent endocrine disorder characterized by dysregulation of calcium homeostasis [ 1 ]. It most commonly results from a solitary parathyroid adenoma (approximately 90% of cases). However, multiple adenomas (3–5%), parathyroid gland hyperplasia (5–9%), or parathyroid carcinoma (< 1%) may also cause this condition [ 2 , 3 ]. The typical parathyroid gland weighs between 50 and 70 milligrams and measures < 2 cm, with a weight < 1 g [ 4 , 5 ]. Giant parathyroid adenomas are uncommon entities in the literature and are greater than 3.5 g in size [ 4 , 6 ]. Patients with GPA tend to exhibit elevated PTH and calcium levels, emphasizing the need for a preoperative study to differentiate them from parathyroid carcinoma [ 4 , 7 ]. While some ultrasound features may suggest GPAs or PCs, these features are typically nonspecific [ 5 , 8 ]. Fine-needle aspiration biopsy has limited sensitivity in distinguishing between GPAs and PCs, and the American Association of Endocrine Surgeons (AAES) does not recommend its routine use [ 9 ]. The following clinical case from Braga Hospital illustrates a case of a large adenoma surgically treated in a patient with chronic kidney disease (CKD). Case Presentation A 74-year-old female patient was referred to the nephrology department for chronic kidney disease (CKD) of unknown etiology. Her past medical history included hypertension, which was diagnosed 15 years prior and was managed with 40 mg of Valsartan daily. During the consultation, she denied habitual use of NSAIDs or a history of recurrent urinary tract infections. During follow-up, several diagnostic tests were conducted, revealing the laboratory abnormalities detailed in Table 1 . Table 1 Laboratory Results Test Parameter Result Reference Range Status Creatinine 2.1 mg/dL 0.6–1.2 mg/dL Increased Calcium 12.3 mg/dL 8.5–10.2 mg/dL Increased PTH 1851 pg/mL 15–65 pg/mL Increased Phosphorus 2.6 mg/dL 2.5–4.5 mg/dL Normal Albumin 4.6 g/dL 3.5-5.0 g/dL Normal The abdominal and pelvic CT scans revealed kidneys with normal topography and slightly lobulated contours, suggesting previous inflammatory events without significant renal atrophy. Nonobstructive calyceal microcalculi were observed in the right kidney, the largest of which measured approximately 4 mm in midsection. No calculi were identified in the left kidney or ureters, and no other significant findings were observed. On the basis of the results of the complementary exams, the patient was referred to a general surgery consultation for suspected primary hyperparathyroidism, and targeted imaging was requested. Thyroid ultrasound revealed a normal thyroid gland. A possible hypertrophied parathyroid gland posterior and inferior to the right thyroid lobe measuring 13x10x23 mm was noted and was recommended to be correlated with laboratory values. No other significant changes were observed. Parathyroid scintigraphy (Fig. 1 ), performed 30 minutes after the injection of 99mTc-sestamibi, revealed a diffuse hyperactive area extending from the right thyroid lobe toward the mediastinum, with retention of the tracer in delayed images. This hyperactivity, particularly on the posterior aspect of the right cervico-mediastinal uptake area, is indicative of a hyperfunctioning parathyroid gland. Given the diagnostic findings, a right inferior parathyroidectomy was performed. Intraoperative inspection revealed no criteria suspicious for malignancy, such as adherence to surrounding structures, invasion, or the presence of adenomegaly. A complete piece measuring approximately 8 cm was extracted (Fig. 2 ), and the surgery was performed without complications. Pathological examination of the sample (Fig. 3 ) revealed nodular tissue formation, with measurements of 7.0 × 3.0 × 1.0 cm and a weight of 12 grams. The morphological characteristics were compatible with parathyroid adenoma. Peripheral examination revealed a partial representation of the capsule, with no lesion breaching the capsule. Postoperatively, the patient developed Hungry bone syndrome and was managed with intravenous calcium gluconate along with oral calcium and calcitriol supplementation. Postoperative PTH levels decreased to 76.71 pg/mL. She was discharged with oral calcium and calcitriol supplementation. The patient continues with regular follow-up, with general surgery, endocrinology, and nephrology. Despite maintaining normal calcium and phosphorus levels, the patient had persistently elevated PTH (PTH 200), indicating hyperparathyroidism associated with CKD. With respect to CKD, the patient continues to have similar creatinine values (1.8 mg/dL), with renal microlithiasis requiring surveillance in nephrology. Discussion Primary hyperparathyroidism (PHP) is predominantly caused by a solitary parathyroid adenoma, typically weighing less than 1 gram, and is associated with elevated serum calcium levels and mildly increased PTH levels. Adenomas weighing more than 3 grams are classified as giant parathyroid adenomas (GPAs). In the described case, the adenoma weighed 12 grams, which is consistent with cases reported in the literature with even greater weights [ 10 – 12 ]. The clinical presentation of PHP has evolved in recent years, with patients more often presenting as asymptomatic. Only a minority of patients exhibit classic PHP symptoms, such as osteitis fibrosa cystica, nephrolithiasis, psychiatric and neurological symptoms, or gastrointestinal disorders [ 7 , 13 ]. Some authors [ 14 , 15 ] have established a direct relationship between adenoma size, severity of hypercalcemia and clinical presentation. Consequently, few asymptomatic GPA cases have been described in the literature [ 16 ]. In most cases, GPAs present with gastrointestinal symptoms or bone fractures [ 5 , 17 , 18 ]. In the described case, the patient had kidney stones and nephropathy, which led to referral to the nephrology clinic for etiological study. The diagnosis of GPA is histological. However, to exclude carcinoma, a comprehensive preoperative study, including imaging studies, should be conducted in addition to laboratory tests. Parathyroid carcinoma is characterized by size, elevated calcium levels, and elevated PTH levels. Ultrasonography and 99mTc-Sestamibi scintigraphy are the first-line imaging methods for parathyroid glands. Ultrasonography has good sensitivity and specificity for lesions larger than 1 cm. Atypical ultrasound features, such as heterogeneous echogenicity, cystic changes, and calcifications, increase the likelihood of diagnosing parathyroid carcinoma [ 19 ]. 99mTc-Sestamibi scintigraphy is generally used when uncertainty exists regarding diagnosis and allows the localization of cells with high metabolic activity, as in parathyroid adenomas. It has good sensitivity and specificity in differentiating GPAs from smaller adenomas, especially when combined with ultrasound [ 4 , 20 ]. In patients suspected of having parathyroid carcinoma or diagnostic doubts, CT and MRI may be considered. In the present case, the findings of benign ultrasound and scintigraphy, which are consistent with a GPA, confirmed the need for CT and MRI. However, intraoperative findings could have altered the surgical approach if suspicions of malignancy arose. Conclusions Giant parathyroid adenomas are rare and should be managed by specialized teams trained in oncological cervical pathology. A comprehensive preoperative study with adequate imaging is essential. Fine-needle aspiration biopsy is not recommended because of its low sensitivity. The surgical team must be prepared for the potential conversion of parathyroidectomy to radical oncological surgery (potentially lateral and central cervical emptying with hemithyroidectomy) to ensure an adequate oncological outcome with complete resection (R0). Abbreviations CKD – Chronic Kidney Disease PTH – Parathyroid Hormone PHPT – Primary Hyperparathyroidism GPA – Giant Parathyroid Adenoma CT – Computed Tomography MRI – Magnetic Resonance Imaging AAES – American Association of Endocrine Surgeons Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding None of the authors mentioned in this article had any funding from any organization or institution. No funding was received for the preparation of this manuscript. Authors' contributions EMMG and PJS were involved in the clinical management of the patient and drafted the manuscript. JPP contributed to the histopathological review. RP performed the imaging analysis. JCP supervised the project and reviewed the final version. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank the surgical, endocrine and nephrology teams involved in the management of the patient. References Barczyński M, Bränström R, Dionigi G, Mihai R. Sporadic multiple parathyroid gland disease—a consensus report of the European Society of Endocrine Surgeons (ESES). Langenbecks Arch Surg dezembro de. 2015;400(8):887–905. Lennard TW. Endocrine Surgery: Companion to Specialist Surgical Practice. Elsevier - Health Sciences Division; 2013. Garas G, Poulasouchidou M, Dimoulas A, Hytiroglou P, Kita M, Zacharakis E. Radiological considerations and surgical planning in the treatment of giant parathyroid adenomas. Ann R Coll Surg Engl. 2015;97(4):e64–6. Al-Hassan MS, Mekhaimar M, El Ansari W, Darweesh A, Abdelaal A. Giant parathyroid adenoma: a case report and review of the literature. J Med Case Rep dezembro de. 2019;13(1):332. Neagoe RM, Sala DT, Borda A, Mogoanta CA. Clinicopathologic and therapeutic aspects of giant parathyroid adenomas - three case reports and short review of the literature. Romanian J Morphol Embryol. 2014;55(2Suppl):669–74. Spanheimer PM, Stoltze AJ, Howe JR, Sugg SL, Lal G, Weigel RJ. Do giant parathyroid adenomas represent a distinct clinical entity? Surgery. 2013;154(4):714–8. discussion 8–9. Madkhali T, Alhefdhi A, Chen H, Elfenbein D. Primary hyperparathyroidism. Ulus Cerrahi Derg. 2016;32(1):58–66. Araujo Castro M, López AA, Fragueiro LM, García NP. Giant parathyroid adenoma: differential aspects compared to parathyroid carcinoma. Endocrinology, Diabetes & Metabolism Case Reports [Internet]. 6 de maio de 2017 [citado 14 de janeiro de 2024];2017. Disponível em: https://edm.bioscientifica.com/view/journals/edm/2017/1/EDM17-0041.xml Kim J, Horowitz G, Hong M, Orsini M, Asa SL, Higgins K. The dangers of parathyroid biopsy. J Otolaryngol Head Neck Surg. 2017;46(1):4. 10.1186/s40463-016-0178-7 . PMID: 28061891; PMCID: PMC5219743. Rutledge S, Harrison M, O'Connell M, O'Dwyer T, Byrne MM. Acute presentation of a giant intrathyroidal parathyroid adenoma: a case report. J Med Case Rep. 2016;10(1):286. 10.1186/s13256-016-1078-1 . Garuna Murthee K, Tay WL, Soo KL, Swee DS. A Migratory Mishap: Giant Mediastinal Parathyroid Adenoma. Am J Med. 2018;131(5):512–6. 10.1016/j.amjmed.2018.01.003 . Mahmodlou R, Sedokani A, Pezeshk A, Najafinejad B. Giant parathyroid adenoma: a case report. J Med Case Rep dezembro de. 2022;16(1):150. Silverberg SJ, Lewiecki EM, Mosekilde L, Peacock M, Rubin MR. Presentation of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab. 2009; 94: 351–365. Rao DS, Honasoge M, Divine GW, Phillips ER, Lee MW, Ansari MR, Talpos GB, Parfitt AM, Effect of vitamin D nutrition on parathyroid adenoma weight: pathogenetic and clinical implications, J Clin Endocrinol Metab, Curlee G, Rowland KJ, van Heerden CM, Thompson JA, Grant GB, Farley CS. DR, The predictive value of laboratory findings in patients with primary hyperparathyroidism, J Am Coll Surg, 2002, 194(2):126–130)). Calva-Cerqueira D, Smith BJ, Hostetler ML, Lal G, Menda Y, O'Dorisio TM, Howe JR. Minimally invasive parathyroidectomy and preoperative MIBI scans: correlation of gland weight and preoperative PTH. J Am Coll Surg. 2007;205(4 Suppl):S38-44. 10.1016/j.jamcollsurg.2007.06.322 . PMID: 17916517. Haldar A, Thapar A, Khan S, Jenkins S. Day-case minimally invasive excision of a giant mediastinal parathyroid adenoma. Ann R Coll Surg Engl., Castro MA, López AA, Fragueiro LM, García NP. Giant parathyroid adenoma: differential aspects compared to parathyroid carcinoma. Endocrinol Diabetes Metab Case Rep. 2017;2017:1. Aggarwal V, Mishra A, Bhargav PR, Ramakant P. Giant parathyroid adenoma. ANZ J Surg. 2009;79(1–2):91. 10.1111/j.1445-2197.2008.04815.x . Sisodiya R, Kumar S, Palankar N. BVD Case report on giant parathyroid adenoma with review of literature. Indian J Surg. 2011;75(Suppl 1):21–2. Chandramohan A, Sathyakumar K, John RA, et al. Atypical ultrasound features of parathyroid tumours may bear a relationship to their clinical and biochemical presentation. Insights Imaging. 2014;5:103–11. https://doi.org/10.1007/s13244-013-0297-x . Yang Z, Zhu L, Wang PZ. Diagnosis and surgical treatment of 48 cases of parathyroid adenoma and parathyroid carcinoma. Chin J Oncol. 2006;28:625–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6197397","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":485199998,"identity":"5120fce7-aba3-40ec-8e23-94c2e8abd2a0","order_by":0,"name":"Eduarda Maria Magalhães Gonçalves","email":"data:image/png;base64,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","orcid":"","institution":"Unidade Local de Saúde, Braga","correspondingAuthor":true,"prefix":"","firstName":"Eduarda","middleName":"Maria Magalhães","lastName":"Gonçalves","suffix":""},{"id":485199999,"identity":"1331221e-0b6e-49b6-9a9f-16ecb734055a","order_by":1,"name":"Paulo J. 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Intraoperative photograph after release of the parathyroid; B. Parathyroid.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6197397/v1/45e3e3eb790b0c1dff5028e2.png"},{"id":86770941,"identity":"8c6aa4ba-c092-4f94-890e-9a1d3b2eb511","added_by":"auto","created_at":"2025-07-15 11:44:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1405941,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA. Proliferation of main cells without cytological atypia (H\u0026amp;E, 400x). B. Representation of the peripheral capsule not exceeded by the lesion (H\u0026amp;E, 100x).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6197397/v1/a122b098f08a2b8e13bbd7ae.png"},{"id":104431520,"identity":"1ce03237-8bc8-4c3a-9985-b698abfe7a2d","added_by":"auto","created_at":"2026-03-11 15:42:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2864324,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6197397/v1/e9578071-828e-4f0e-b35a-b6e22f4ba63d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Rare Presentation of Giant Parathyroid Adenoma in the Context of Chronic Kidney Disease: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary hyperparathyroidism is a prevalent endocrine disorder characterized by dysregulation of calcium homeostasis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It most commonly results from a solitary parathyroid adenoma (approximately 90% of cases). However, multiple adenomas (3–5%), parathyroid gland hyperplasia (5–9%), or parathyroid carcinoma (\u0026lt; 1%) may also cause this condition [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The typical parathyroid gland weighs between 50 and 70 milligrams and measures \u0026lt; 2 cm, with a weight \u0026lt; 1 g [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Giant parathyroid adenomas are uncommon entities in the literature and are greater than 3.5 g in size [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Patients with GPA tend to exhibit elevated PTH and calcium levels, emphasizing the need for a preoperative study to differentiate them from parathyroid carcinoma [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. While some ultrasound features may suggest GPAs or PCs, these features are typically nonspecific [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Fine-needle aspiration biopsy has limited sensitivity in distinguishing between GPAs and PCs, and the American Association of Endocrine Surgeons (AAES) does not recommend its routine use [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The following clinical case from Braga Hospital illustrates a case of a large adenoma surgically treated in a patient with chronic kidney disease (CKD).\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 74-year-old female patient was referred to the nephrology department for chronic kidney disease (CKD) of unknown etiology. Her past medical history included hypertension, which was diagnosed 15 years prior and was managed with 40 mg of Valsartan daily. During the consultation, she denied habitual use of NSAIDs or a history of recurrent urinary tract infections.\u003c/p\u003e\u003cp\u003eDuring follow-up, several diagnostic tests were conducted, revealing the laboratory abnormalities detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLaboratory Results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest Parameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResult\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReference Range\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStatus\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCreatinine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.1 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6–1.2 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIncreased\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCalcium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.3 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.5–10.2 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIncreased\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePTH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1851 pg/mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15–65 pg/mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIncreased\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhosphorus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.6 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.5–4.5 mg/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.6 g/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.5-5.0 g/dL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe abdominal and pelvic CT scans revealed kidneys with normal topography and slightly lobulated contours, suggesting previous inflammatory events without significant renal atrophy. Nonobstructive calyceal microcalculi were observed in the right kidney, the largest of which measured approximately 4 mm in midsection. No calculi were identified in the left kidney or ureters, and no other significant findings were observed.\u003c/p\u003e\u003cp\u003eOn the basis of the results of the complementary exams, the patient was referred to a general surgery consultation for suspected primary hyperparathyroidism, and targeted imaging was requested. Thyroid ultrasound revealed a normal thyroid gland. A possible hypertrophied parathyroid gland posterior and inferior to the right thyroid lobe measuring 13x10x23 mm was noted and was recommended to be correlated with laboratory values. No other significant changes were observed.\u003c/p\u003e\u003cp\u003eParathyroid scintigraphy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), performed 30 minutes after the injection of 99mTc-sestamibi, revealed a diffuse hyperactive area extending from the right thyroid lobe toward the mediastinum, with retention of the tracer in delayed images. This hyperactivity, particularly on the posterior aspect of the right cervico-mediastinal uptake area, is indicative of a hyperfunctioning parathyroid gland.\u003c/p\u003e\u003cp\u003eGiven the diagnostic findings, a right inferior parathyroidectomy was performed. Intraoperative inspection revealed no criteria suspicious for malignancy, such as adherence to surrounding structures, invasion, or the presence of adenomegaly.\u003c/p\u003e\u003cp\u003eA complete piece measuring approximately 8 cm was extracted (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and the surgery was performed without complications.\u003c/p\u003e\u003cp\u003ePathological examination of the sample (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) revealed nodular tissue formation, with measurements of 7.0 × 3.0 × 1.0 cm and a weight of 12 grams. The morphological characteristics were compatible with parathyroid adenoma. Peripheral examination revealed a partial representation of the capsule, with no lesion breaching the capsule.\u003c/p\u003e\u003cp\u003ePostoperatively, the patient developed Hungry bone syndrome and was managed with intravenous calcium gluconate along with oral calcium and calcitriol supplementation.\u003c/p\u003e\u003cp\u003ePostoperative PTH levels decreased to 76.71 pg/mL. She was discharged with oral calcium and calcitriol supplementation. The patient continues with regular follow-up, with general surgery, endocrinology, and nephrology. Despite maintaining normal calcium and phosphorus levels, the patient had persistently elevated PTH (PTH 200), indicating hyperparathyroidism associated with CKD. With respect to CKD, the patient continues to have similar creatinine values (1.8 mg/dL), with renal microlithiasis requiring surveillance in nephrology.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrimary hyperparathyroidism (PHP) is predominantly caused by a solitary parathyroid adenoma, typically weighing less than 1 gram, and is associated with elevated serum calcium levels and mildly increased PTH levels. Adenomas weighing more than 3 grams are classified as giant parathyroid adenomas (GPAs). In the described case, the adenoma weighed 12 grams, which is consistent with cases reported in the literature with even greater weights [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The clinical presentation of PHP has evolved in recent years, with patients more often presenting as asymptomatic. Only a minority of patients exhibit classic PHP symptoms, such as osteitis fibrosa cystica, nephrolithiasis, psychiatric and neurological symptoms, or gastrointestinal disorders [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Some authors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] have established a direct relationship between adenoma size, severity of hypercalcemia and clinical presentation. Consequently, few asymptomatic GPA cases have been described in the literature [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In most cases, GPAs present with gastrointestinal symptoms or bone fractures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the described case, the patient had kidney stones and nephropathy, which led to referral to the nephrology clinic for etiological study.\u003c/p\u003e\u003cp\u003eThe diagnosis of GPA is histological. However, to exclude carcinoma, a comprehensive preoperative study, including imaging studies, should be conducted in addition to laboratory tests. Parathyroid carcinoma is characterized by size, elevated calcium levels, and elevated PTH levels. Ultrasonography and 99mTc-Sestamibi scintigraphy are the first-line imaging methods for parathyroid glands. Ultrasonography has good sensitivity and specificity for lesions larger than 1 cm. Atypical ultrasound features, such as heterogeneous echogenicity, cystic changes, and calcifications, increase the likelihood of diagnosing parathyroid carcinoma [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. 99mTc-Sestamibi scintigraphy is generally used when uncertainty exists regarding diagnosis and allows the localization of cells with high metabolic activity, as in parathyroid adenomas. It has good sensitivity and specificity in differentiating GPAs from smaller adenomas, especially when combined with ultrasound [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In patients suspected of having parathyroid carcinoma or diagnostic doubts, CT and MRI may be considered. In the present case, the findings of benign ultrasound and scintigraphy, which are consistent with a GPA, confirmed the need for CT and MRI. However, intraoperative findings could have altered the surgical approach if suspicions of malignancy arose.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGiant parathyroid adenomas are rare and should be managed by specialized teams trained in oncological cervical pathology. A comprehensive preoperative study with adequate imaging is essential. Fine-needle aspiration biopsy is not recommended because of its low sensitivity. The surgical team must be prepared for the potential conversion of parathyroidectomy to radical oncological surgery (potentially lateral and central cervical emptying with hemithyroidectomy) to ensure an adequate oncological outcome with complete resection (R0).\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCKD \u0026ndash; Chronic Kidney Disease\u003c/p\u003e\u003cp\u003ePTH \u0026ndash; Parathyroid Hormone\u003c/p\u003e\u003cp\u003ePHPT \u0026ndash; Primary Hyperparathyroidism\u003c/p\u003e\u003cp\u003eGPA \u0026ndash; Giant Parathyroid Adenoma\u003c/p\u003e\u003cp\u003eCT \u0026ndash; Computed Tomography\u003c/p\u003e\u003cp\u003eMRI \u0026ndash; Magnetic Resonance Imaging\u003c/p\u003e\u003cp\u003eAAES \u0026ndash; American Association of Endocrine Surgeons\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Written informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003eNone of the authors mentioned in this article had any funding from any organization or institution. No funding was received for the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;EMMG and PJS were involved in the clinical management of the patient and drafted the manuscript. JPP contributed to the histopathological review. RP performed the imaging analysis. JCP supervised the project and reviewed the final version. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors would like to thank the surgical, endocrine and nephrology teams involved in the management of the patient.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarczyński M, Br\u0026auml;nstr\u0026ouml;m R, Dionigi G, Mihai R. Sporadic multiple parathyroid gland disease\u0026mdash;a consensus report of the European Society of Endocrine Surgeons (ESES). Langenbecks Arch Surg dezembro de. 2015;400(8):887\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLennard TW. Endocrine Surgery: Companion to Specialist Surgical Practice. Elsevier - Health Sciences Division; 2013.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGaras G, Poulasouchidou M, Dimoulas A, Hytiroglou P, Kita M, Zacharakis E. Radiological considerations and surgical planning in the treatment of giant parathyroid adenomas. Ann R Coll Surg Engl. 2015;97(4):e64\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Hassan MS, Mekhaimar M, El Ansari W, Darweesh A, Abdelaal A. Giant parathyroid adenoma: a case report and review of the literature. J Med Case Rep dezembro de. 2019;13(1):332.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeagoe RM, Sala DT, Borda A, Mogoanta CA. Clinicopathologic and therapeutic aspects of giant parathyroid adenomas - three case reports and short review of the literature. Romanian J Morphol Embryol. 2014;55(2Suppl):669\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpanheimer PM, Stoltze AJ, Howe JR, Sugg SL, Lal G, Weigel RJ. Do giant parathyroid adenomas represent a distinct clinical entity? Surgery. 2013;154(4):714\u0026ndash;8. discussion 8\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadkhali T, Alhefdhi A, Chen H, Elfenbein D. Primary hyperparathyroidism. Ulus Cerrahi Derg. 2016;32(1):58\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAraujo Castro M, L\u0026oacute;pez AA, Fragueiro LM, Garc\u0026iacute;a NP. Giant parathyroid adenoma: differential aspects compared to parathyroid carcinoma. Endocrinology, Diabetes \u0026amp; Metabolism Case Reports [Internet]. 6 de maio de 2017 [citado 14 de janeiro de 2024];2017. Dispon\u0026iacute;vel em: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://edm.bioscientifica.com/view/journals/edm/2017/1/EDM17-0041.xml\u003c/span\u003e\u003cspan address=\"https://edm.bioscientifica.com/view/journals/edm/2017/1/EDM17-0041.xml\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim J, Horowitz G, Hong M, Orsini M, Asa SL, Higgins K. The dangers of parathyroid biopsy. J Otolaryngol Head Neck Surg. 2017;46(1):4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40463-016-0178-7\u003c/span\u003e\u003cspan address=\"10.1186/s40463-016-0178-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 28061891; PMCID: PMC5219743.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRutledge S, Harrison M, O'Connell M, O'Dwyer T, Byrne MM. Acute presentation of a giant intrathyroidal parathyroid adenoma: a case report. J Med Case Rep. 2016;10(1):286. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13256-016-1078-1\u003c/span\u003e\u003cspan address=\"10.1186/s13256-016-1078-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGaruna Murthee K, Tay WL, Soo KL, Swee DS. A Migratory Mishap: Giant Mediastinal Parathyroid Adenoma. Am J Med. 2018;131(5):512\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjmed.2018.01.003\u003c/span\u003e\u003cspan address=\"10.1016/j.amjmed.2018.01.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMahmodlou R, Sedokani A, Pezeshk A, Najafinejad B. Giant parathyroid adenoma: a case report. J Med Case Rep dezembro de. 2022;16(1):150.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSilverberg SJ, Lewiecki EM, Mosekilde L, Peacock M, Rubin MR. Presentation of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab. 2009; 94: 351\u0026ndash;365.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRao DS, Honasoge M, Divine GW, Phillips ER, Lee MW, Ansari MR, Talpos GB, Parfitt AM, Effect of vitamin D nutrition on parathyroid adenoma weight: pathogenetic and clinical implications, J Clin Endocrinol Metab, Curlee G, Rowland KJ, van Heerden CM, Thompson JA, Grant GB, Farley CS. DR, The predictive value of laboratory findings in patients with primary hyperparathyroidism, J Am Coll Surg, 2002, 194(2):126\u0026ndash;130)).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCalva-Cerqueira D, Smith BJ, Hostetler ML, Lal G, Menda Y, O'Dorisio TM, Howe JR. Minimally invasive parathyroidectomy and preoperative MIBI scans: correlation of gland weight and preoperative PTH. J Am Coll Surg. 2007;205(4 Suppl):S38-44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jamcollsurg.2007.06.322\u003c/span\u003e\u003cspan address=\"10.1016/j.jamcollsurg.2007.06.322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 17916517.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaldar A, Thapar A, Khan S, Jenkins S. Day-case minimally invasive excision of a giant mediastinal parathyroid adenoma. Ann R Coll Surg Engl., Castro MA, L\u0026oacute;pez AA, Fragueiro LM, Garc\u0026iacute;a NP. Giant parathyroid adenoma: differential aspects compared to parathyroid carcinoma. Endocrinol Diabetes Metab Case Rep. 2017;2017:1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAggarwal V, Mishra A, Bhargav PR, Ramakant P. Giant parathyroid adenoma. ANZ J Surg. 2009;79(1\u0026ndash;2):91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1445-2197.2008.04815.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1445-2197.2008.04815.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSisodiya R, Kumar S, Palankar N. BVD Case report on giant parathyroid adenoma with review of literature. Indian J Surg. 2011;75(Suppl 1):21\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChandramohan A, Sathyakumar K, John RA, et al. Atypical ultrasound features of parathyroid tumours may bear a relationship to their clinical and biochemical presentation. Insights Imaging. 2014;5:103\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s13244-013-0297-x\u003c/span\u003e\u003cspan address=\"10.1007/s13244-013-0297-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang Z, Zhu L, Wang PZ. Diagnosis and surgical treatment of 48 cases of parathyroid adenoma and parathyroid carcinoma. Chin J Oncol. 2006;28:625\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6197397/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6197397/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePrimary hyperparathyroidism (PHPT), a common endocrine disorder, disrupts calcium homeostasis and frequently arises from a parathyroid adenoma. In rare instances, giant parathyroid adenomas (GPAs), defined as those weighing more than 3.5 grams, may develop, posing diagnostic challenges, particularly in distinguishing them from parathyroid carcinoma (PC). A 74-year-old female patient with chronic kidney disease (CKD) of undetermined origin was referred for evaluation of suspected PHPT. Laboratory investigations revealed elevated serum calcium and parathyroid hormone (PTH) levels. Scintigraphy and ultrasonography suggested the presence of a GPA, leading to parathyroidectomy. Histopathological analysis of the resected adenoma confirmed a weight of 12 grams. While PHPT is often associated with smaller adenomas and may be asymptomatic, GPAs typically manifest with clinical symptoms. Imaging modalities, such as ultrasound and scintigraphy, are crucial in differentiating GPAs from PCs. These cases are uncommon and necessitate specialized management strategies. A comprehensive preoperative assessment, including appropriate imaging, is vital; fine-needle aspiration biopsy has low sensitivity. In cases of GPA, the surgical team must be prepared for potential conversion to radical oncological surgery to ensure complete resection.\u003c/p\u003e","manuscriptTitle":"A Rare Presentation of Giant Parathyroid Adenoma in the Context of Chronic Kidney Disease: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 11:36:26","doi":"10.21203/rs.3.rs-6197397/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c1ea71e-6873-412c-b6a9-db09f8215104","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T15:41:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 11:36:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6197397","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6197397","identity":"rs-6197397","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}