A 48-year-old man has primary hyperparathyroidism with serum calcium 15.2 mg/dL and intact PTH 1100 pg/mL. He has a hard, palpable 3 cm left neck mass, hoarseness, and a serum creatinine of 2.1 mg/dL. Ultrasound suggests invasion of adjacent soft tissue. Which additional intraoperative finding would most strongly support malignancy rather than benign disease?

• A Whitish fibrous bands traversing the gland capsule ✓
• B The gland is encapsulated and freely mobile
• C The gland weighs over 1 gram
• D Intraoperative PTH falls by more than 50 percent after excision

Explanation

Parathyroid carcinoma presents with very high calcium (often above 14 mg/dL) and PTH frequently exceeding three times normal, plus a palpable hard mass, hoarseness from recurrent laryngeal involvement and renal impairment. Grossly it is a firm pale grey gland with whitish fibrous capsular thickening and bands. C large gland alone favours adenoma, a well-encapsulated mobile gland favours adenoma, and a fall in PTH after excision indicates complete removal rather than histological behaviour.

Reference: Schwartz Principles of Surgery, 11th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.