Parathyroid Adenoma Research Articles

Opportunistic Assessment for Parathyroid Adenoma on CT: A Retrospective Cohort Study Evaluating Primary Hyperparathyroidism-Associated Morbidity Over 10 Years of Follow-Up.

Background: Primary hyperparathyroidism (PHPT) is underdiagnosed. Opportunistic imaging-based parathyroid gland assessment is a proposed strategy for identifying patients at increased risk of undiagnosed PHPT. However, whether this approach is likely to identify individuals with clinically significant disease is unknown. Objective: This study's objective was to assess for associations of the presence of an enlarged parathyroid gland on contrast-enhanced CT with clinical outcomes causally related to PHPT. Methods: This retrospective cohort study included patients age 18 years old or older with at least one contrast-enhanced chest or neck CT performed from January 2012 to December 2012, at least one noncontrast CT covering the chest or neck region without date restriction, and at least one clinical encounter in the health system from January 2022 to December 2022. A neuroradiologist reviewed the CT examinations to determine the presence versus absence of an enlarged parathyroid gland on the 2012 study. Patient demographics, serum calcium results, and diagnosis codes for clinical outcomes causally related to PHPT were extracted from the EHR. Calcium results and diagnosis codes were classified as pre-existing if documented before, and as incident if documented after, the 2012 contrast-enhanced CT examination. Results: The cohort included 1198 patients (593 male; 605 female; mean age, 51.6 years), of whom 43 (3.6%) were assessed as having an enlarged parathyroid gland on the 2012 contrast-enhanced CT examination. PHPT was diagnosed in 16.3% of patients with, versus 0.3% of patients without, an enlarged parathyroid gland. After adjusting for age, sex, race, and ethnicity, presence of an enlarged parathyroid gland was associated with significantly increased odds of pre-existing nephrolithiasis (OR=2.71; p=.03), hypercalcemia (OR=5.30; p<.001), and PHPT (OR=12.59; p=.008) as well as increased odds of incident osteopenia or osteoporosis (OR=2.78; p=.008), nephrolithiasis (OR=4.95; p<.001), hypercalcemia (OR=7.58; p<.001), and PHPT (OR=148.01; p<.001). Conclusion: An enlarged parathyroid gland indicated increased PHPT risk as well as increased risk of pre-existing and incident clinical conditions causally related to PHPT. Clinical Impact: Opportunistic CT-based assessment is a promising strategy for identifying patients at increased risk of undiagnosed PHPT; such assessment could potentially prevent some PHPT-related complications through earlier diagnosis and treatment.

Somatostatin Receptor Imaging in the Diagnosis and Management of Parathyroid Neuroendocrine Neoplasia

Background: Parathyroid tumors are classified as parathyroid neuroendocrine neoplasia (NEN) by the IARC-WHO classification. These tumors can occur with NENs from other sites, which often require total-body [68Ga]-DOTA-peptides PET/CT. This study aimed to assess the utility of [68Ga]-DOTA-peptide PET/CT in imaging parathyroid NENs and to evaluate the underlying mechanisms. Methods: Fifty patients with primary hyperparathyroidism (PHPT) and parathyroid NENs histologically confirmed as parathyroid adenomas (PAs) were included. PET/CT with [68Ga]-DOTA-peptide was performed in 16 patients with localized PAs, including 10 with MEN1 syndrome. Somatostatin receptor types 2 and 5 (SST2 and SST5) staining was performed on PAs from 48 patients. Somatostatin analogs (SSA) were prescribed in four patients with MEN 1 syndrome and 1 with persistent acromegaly, all with PAs and PHPT. The therapy effects on calcium and parathyroid hormone (iPTH) were evaluated. Results: [68Ga]-DOTA-peptide PET/CT detected 20 PAs with high radiopharmaceutical uptake. SST2 expression was negative on PA cell membranes in all cases and positive on endothelium in 39 (81%) PAs. Membrane SST5 expression was positive in 25 (52%) PAs and endothelial was positive in 40 (83%). Serum calcium levels decreased in patients on SSA therapy, while iPTH did not. Conclusions: PET/CT with [68Ga]-DOTA-peptides can detect parathyroid NENs. The incidental detection of high [68Ga]-DOTA-peptide uptake in the parathyroid region during whole-body PET/CT may prompt biochemical evaluation for PHPT. We suggest that endothelial SST expression mediates high radiopharmaceutical uptake by PAs and that SSA treatment can reduce hypercalcemia in PHPT patients.

A Singular Case of Adenomyoma of Ampulla with Parathyroid Adenoma - A Rarest of Rare Association

A Singular Case of Adenomyoma of Ampulla with Parathyroid Adenoma - A Rarest of Rare Association

Near-Infrared Autofluorescence or Intraoperative Parathyroid Hormone Determination as a Surgical Support Tool in Primary Hyperparathyroidism: Too Close to Call?

Background: This study investigates the use of near-infrared fluorescence imaging (NIFI) as an alternative to intraoperative parathyroid hormone (ioPTH) measurement in patients with primary hyperparathyroidism (PHP) due to parathyroid adenoma (PA) with two preoperative imaging examinations in agreement on the position of the altered parathyroid gland. Methods: Fifty patients who underwent minimally invasive parathyroidectomy (MIP) from March 2021 to April 2024 were enrolled. MIPs utilised both NIFI and ioPTH, comparing the time to adenoma excision with NIFI against the total surgical time, including ioPTH measurement wait time. Results: Results showed successful MIPs in all patients, with a mean excision time of 44.7 min (SD ± 25.2) and a total procedure time of 85.5 min (SD ± 37.1). The median of the duration of the surgical procedure until adenoma excision was 35.0 min (IQR 38.8), while the median duration of the entire procedure was 74.5 min (IQR 40.5). This difference in medians is statistically significant using the Wilcoxon non-parametric test for paired samples (p &lt; 0.001). The average wait for ioPTH results post-excision was 37 min (SD ± 12.2). Three fluorescence patterns were identified: “cap” (46%), heterogeneous (30%), and homogeneous (24%). Conclusions: If preoperative imaging confirms PA location, NIFI could replace ioPTH reducing surgical time without compromising success rates.

Aberrant promoter methylation, expression and function of RASSF1A gene in a series of Italian parathyroid tumors.

Aberrant epigenetic features are key events involved in parathyroid tumorigenesis, including DNA methylation, histone methylation, and non-coding RNAs. Ras Association Domain Family Protein1 Isoform A (RASSF1A) and Adenomatous Polyposis of Colon (APC) are frequently downregulated in human cancers. Here, we investigated their deregulated expression and the potential role in parathyroid neoplasms. methylation of RASSF1A and APC promoters was analyzed in a series of parathyroid adenomas (PAds, n = 80) and parathyroid carcinomas (PCas, n = 9) from Italian patients with primary hyperparathyroidism, RESULTS: RASSF1A and APC promoter methylation occurred in about 90% of PAds samples. PCas displayed RASSF1A promoter methylation, while APC promoter was methylated only in 2 samples. Of note, RASSF1A promoter methylation negatively correlated with PAds tumor size. However, RASSF1A transcript and protein levels were reduced in PAds and PCas compared with parathyroid normal glands. Investigating the potential mechanism involved in RASSF1A promoter methylation, we found that DNA methyltransferases (DNMTs) activity was variable in PAds and inversely correlated with RASSF1A protein levels. In addition, the RASSF1A promoter methylation negatively correlated with long-non-coding Antisense Intronic Noncoding RASSF1A (ANRASSF1A) mRNA levels, excluding the involvement of ANRASSF1 in RASSF1A regulation. In HEK293A cells transfected with the calcium sensing receptor (CASR), loss of RASSF1A increased basal phosphorylated Extracellular signal-regulated kinase (pERK/ERK) levels blunting the CASR-induced increases. RASSF1A and APC promoter methylation is a hallmark of parathyroid tumors; deregulation of DNMTs activity contributes to modulation of RASSF1A expression. Loss of RASSF1A may be involved in the tuning of ERK pathway in parathyroid tumors.

Primary hyperparathyroidism in a giant parathyroid adenoma: A first case report in Jazan, Southern Region, Saudi Arabia

Primary hyperparathyroidism in a giant parathyroid adenoma: A first case report in Jazan, Southern Region, Saudi Arabia

48-Year clinical experience and genetic analysis of pediatric primary hyperparathyroidism from a single center in China.

This study aims to investigate the clinical and genetic features and change of clinical spectrum of primary hyperparathyroidism (PHPT) in children and adolescents. The clinical and follow-up data of 74 pediatric patients (onset age ≤ 18 years) with PHPT during 1975-2022 were retrospectively analyzed. For comparison, patients were divided into four subgroups according to their time of diagnosis. Genetic analysis was conducted in 40 patients. Pediatric PHPT cases increased largely over time [34 cases (45.9%) in 2015-2022]. The rate of asymptomatic PHPT increased by time (14.7% in 2015-2022 vs. 0% before 2015), in accordance with routine screening of serum calcium becoming a more frequent reason for clinic visit (17.6% in 2015-2022 vs. 0% before 2015). Skeletal manifestation significantly decreased in recent years (64.7% in 2015-2022 vs. 100.0% in 1975-1994, P < 0.05). Sixty-seven patients (90.5%) of the whole cohort underwent parathyroidectomy. Atypical parathyroid adenoma and parathyroid carcinoma occurred in 13.4% and 4.5% of the surgical cases, respectively. Recurrence and persistence of PHPT were observed in 17.9% of postsurgical patients. Germline rare variations (RVs) of PHPT-related genes were found in 42.5% (17/40) of all cases with genetic testing. Compared with no-variation group, the variation group had higher incidence of multiple parathyroid lesions (42.8% vs. 4.3%, P = 0.014), and lower rate of benign lesions and higher rate of recurrence and persistence. Milder cases of Pediatric PHPT are coming to clinical attention probably due to routine lab testing. Genetic testing is recommended for pediatric PHPT patients.

Glycomic profiling of parathyroid neoplasms via lectin microarray analysis.

Parathyroid carcinoma (PC) is a rare malignancy with a poor prognosis. Diagnosis of PC is often difficult in clinical practice and efficient diagnostic markers are still needed for differential diagnosis. Aberrant glycosylations of glycoproteins were identified with lectin microarray in various cancers, while relevant information is lacking in PC. In this study, 8 PC and 6 parathyroid adenoma (PA) tissues were assessed using a microarray consisting of 70 lectins. Overall lectin-specific glycosylation patterns were compared between PA and PC tissues. Lectins with significant differential response between PC and PA were further validated by lectin histochemistry. The difference in signal intensities was found in 71.4% (50/70) of the lectins between the two groups (P < 0.05). The vast majority of PCs had higher intensity signals than PAs (PCs vs. PAs, ratio >1) and amaranthus caudatus (ACL) showed the most significantly different response between them (ratio = 2.45). Lectin histochemistry further confirmed higher ACL intensity in PCs than in PAs. The differentially expressed glycans in PC tissues were primarily glucose, mannose, and galactose-based. PC presented unique glycomic features and ACL may serve as a candidate diagnostic marker for PC.

CDC73 c.1155-3A &amp;gt; G is a pathogenic variant that causes aberrant splicing, disrupted parafibromin expression and hyperparathyroidism-jaw tumor syndrome

Abstract Germline and somatic pathogenic variants in the CDC73 gene, encoding the nuclear protein parafibromin, increase the risk for parathyroid carcinoma and cause hereditary primary hyperparathyroidism (PHPT) syndromes known as familial isolated hyperparathyroidism (FIHP) and hyperparathyroidism-jaw tumor syndrome (HPT-JT). The identification of pathogenic germline variants in PHPT-susceptibility genes can influence surgical planning for parathyroidectomy, guide screening for potential syndromic manifestations, and identify/exonerate at-risk family members. Numerous types of pathogenic germline variants have been described for CDC73-related conditions including deletion, truncating, missense, and splice site mutations. Here, we report identification of a non-coding germline CDC73 variant (CDC73 c.1155-3A &amp;gt; G), previously categorized as a variant of uncertain significance (VUS), in a family with HPT-JT. This variant, found in two family members with PHPT, altered CDC73 splicing in peripheral blood cells and disrupted parafibromin immunostaining in associated parathyroid adenomas: strongly evidencing its pathogenicity. Sestamibi scintigraphy yielded nondiagnostic localization results for both patients’ parathyroid adenomas, consistent with prior studies suggesting lower sensitivity for small or cystic lesions. Our findings demonstrate key aspects of CDC73-related disorders, highlight the diagnostic value of RNA testing and exemplify the importance of obtaining a thorough, three-generational family history.

A giant parathyroid adenoma: a case report

BackgroundPrimary hyperparathyroidism is an endocrine disease and a common cause of nonmalignant hypercalcemia, often discovered incidentally in asymptomatic patients. The case reported herein illustrates that significant hormonal imbalances can present with unexpectedly mild clinical manifestations.Case presentationWe describe a 47-year-old Caucasian male with two episodes of kidney stones and otherwise no symptoms of severe hypercalcemia. In our case, fasting emerged as a potential risk factor for the development of renal stones. The diagnosis was primary hyperparathyroidism. The intervention consisted of preoperative fluids and cinacalcet while awaiting surgery. Despite initial stability, the patient experienced a subsequent increase in ionized calcium and parathyroid hormone levels, becoming symptomatic with fatigue, tremors, and heart palpitations. This progression led to a diagnosis of a hypercalcemic crisis, and the plan was accelerated. An acute parathyroid scintigraphy and an ultrasound was performed and revealed a giant intrathoracic parathyroid adenoma. After surgical removal of the adenoma, he developed hungry bones and biochemical remission. The patient has received three extracorporeal shock wave lithotripsy treatments for a stone in the upper left kidney, but as of a computed tomography scan on 9 February 2024, the stone remains unchanged. Owing to the stone’s resistance to extracorporeal shock wave lithotripsy and the absence of symptoms, no further treatment is planned. Endoscopic laser treatment (retrograde intrarenal surgery) is an option, but for now, the situation will be monitored.ConclusionThis case report underscores that extremely elevated levels of calcium and parathyroid hormone along with a rare giant parathyroid adenoma may not necessarily present with symptoms indicative of a calcium crisis. Additionally, management of such rare giant parathyroid adenomas requires careful monitoring and a tailored approach to address potential postsurgical complications such as hungry bone syndrome.

Unveiling a rare endocrine puzzle: A case of CDKN1B mutation-associated MEN4 syndrome

A woman with a prior diagnosis of thyroid dysfunction was found to have hyperprolactinemia and incidental hypercalcemia. Further investigation led to the diagnosis of a parathyroid adenoma. The unique constellation of hormonal abnormalities and multifocal thyroid nodules defied explanation by known MEN syndromes (no family history). We report the identification of a heterozygous p.Val109Gly mutation in CDKN1B, a gene associated with MEN4 syndrome, through targeted genetic testing. The presented case expands the phenotypic spectrum of MEN4 and highlights the utility of genetic testing in diagnosing syndromic forms of endocrine hyperplasias.

A case series on parathyroid carcinoma: Diagnostic challenges and therapeutic approaches

IntroductionParathyroid carcinoma is an exceptionally rare endocrine malignancy, constituting <1 % of primary hyperparathyroidism (PHPT) cases. It presents with more severe hypercalcemia and higher PTH levels than benign parathyroid diseases, requiring increased clinical awareness for accurate identification and specialized management. The results of this case series may provide insight into the clinical presentation, diagnostic workup, surgical management, and prognosis of parathyroid carcinoma, supplemented by a comprehensive review of current diagnostic and therapeutic approaches. MethodsWe retrospectively reviewed three cases of parathyroid carcinoma treated at a tertiary referral hospital. We analyzed patient demographics, clinical presentation, imaging studies, surgical interventions, histopathological findings, and follow-up data. We emphasized intraoperative decisions, criteria for achieving sustained hormonal control, and long-term monitoring protocols. ResultsPatient 1: An 84-year-old male patient presented with severe hypercalcemia and elevated PTH levels. Preoperative imaging, including 4D CT and sestamibi scan, identified a 3.7 cm, 9.32-gram parathyroid mass, which was surgically resected. Despite removing the mass and normalizing calcium levels, PTH levels remained elevated, suggesting residual disease.Patient 2: A 77-year-old male patient with osteoporosis and a history of kidney stones underwent presurgical parathyroid scintigraphy, which indicated a right superior parathyroid adenoma. A 3 cm, 3.55-gram parathyroid carcinoma was successfully removed, normalizing calcium and PTH levels. Follow-up imaging and labs confirmed no recurrence.Patient 3: A 61-year-old female patient with end-stage renal disease presented with a 5 cm hypervascular neck mass. Preoperative 4D CT and ultrasound suggested an adenoma. After surgery, PTH levels normalized, but the patient died five years later from an unrelated stroke. ConclusionParathyroid carcinoma is a rare malignancy that demands thorough diagnostic procedures, imaging techniques, precise surgical intervention, and vigilant long-term follow-up to manage the risk of recurrence. Elevated PTH and calcium levels should raise suspicion of malignancy, especially in severe hypercalcemia. This case series illustrates how the disease can present variably, with unique challenges in each patient. Despite the limitations of current adjuvant therapies, advancements in genetic and molecular research hold promise for future therapeutic options.

Investigation of the function of the parathyroid glands during thyroid surgery.

Annotation The aim is to justify the need for a routine examination of the function of the parathyroid glands in all patients before thyroid surgery. Materials and methods The analysis of 249 patients who underwent thyroid surgery was carried out. All patients were divided into 2 groups. The main criterion for division is a routine assessment of the function of the parathyroid glands before thyroid surgery. In each group, we assessed the need for interventions on the parathyroid glands. Results In 3 patients of group I, in the period 3-5 months after thyroid surgery, an “unreasonable” increase in blood calcium levels was revealed. Upon further examination, laboratory and clinical signs of primary hyperaparthyroidism were revealed in them. These patients (2.1%) required surgery on the parathyroid gland. There were no such patients in the second group. According to the results of preoperative examination in group II, an increase in parathyroid hormone levels was detected in 32 (28%) patients. Parathyroid adenomas were confirmed in 9 (28%) of 32 patients with hyperparathyroidism. At the same time, according to ultrasound, adenomas were visualized only in 5 (56%). In retrospective analysis, all 9 patients showed signs of damage to target organs without pronounced clinical manifestations. All these 9 patients underwent simultaneous intervention on the thyroid and parathyroid glands. In this group of patients, the frequency of simultaneous operations was 8% (p 0.001). Conclusion Before performing surgery on the thyroid gland, it is advisable for all patients to conduct a routine examination of blood calcium and parathyroid hormone to determine the indications for surgery on the parathyroid gland. With this approach, laboratory and clinical signs of primary hyperparathyroidism can be detected in 8% of patients with thyroid pathology, which requires simultaneous operations. Key words: hyperparathyroidism; calcium; nephrolithiasis; parathyroid hormone; parathyroidectomy; thyroid gland. Conflict of interest: none.

Impact of Histological Subtypes on Preoperative Localization of Parathyroid Adenomas

Introduction: Parathyroid scintigraphy and ultrasonography are the primary imaging methods used for localizing parathyroid adenomas. However, there remains a risk of missed or failed localization. This study aims to investigate the relationship between clinical and pathological findings in patients with parathyroid adenoma, focusing on the causes behind missed adenomas and localization failures. Patients and Methods: We analyzed the demographic, clinical, laboratory, and radiological data of patients who underwent surgery for primary hyperparathyroidism due to adenomas. Additionally, we reassessed the adenomas' pathologic characteristics, including size, weight, dominant cell type, and the percentage of oxyphilic cells. Results: A total of 115 patients were studied, with dominant cell types distributed as follows: 83 (71.6%) conventional chief cells, 15 (12.9%) water-clear cells, and 17 (14.7%) oxyphilic cells. The average percentage of oxyphilic cells was 21.15%. The localization rate via ultrasonography was significantly lower in the water-clear cell group (p &lt; 0.05). While not statistically significant, the localization success using scintigraphy was lower in the oxyphilic cell group compared to others (58.8% vs. 80.7% and 86.7%). Our findings suggest that histological subtypes of parathyroid adenomas, particularly dominant cell content, may affect preoperative localization success. Conclusion: Missed parathyroid adenomas may be attributed to their histological subtypes and dominant cell composition. These factors could influence the accuracy of preoperative localization with ultrasonography and scintigraphy.

Parathyroid apoplexy from giant adenoma with mediastinal extension: A case report

&lt;b&gt;Introduction&lt;/b&gt;: Primary hyperparathyroidism (PHPT) results from an excess secretion of parathyroid hormone (PTH), primarily due to parathyroid adenomas. These adenomas are more prevalent in women and, although rare, can develop into giant adenomas. One infrequent but notable complication of giant adenomas is parathyroid apoplexy. The aim of this manuscript is to describe the case of a Peruvian female patient diagnosed with PHPT secondary to a giant parathyroid adenoma, whose surgical treatment confirmed its apoplexy.&lt;br /&gt; &lt;b&gt;Case report&lt;/b&gt;: A 42-year-old Peruvian woman with hypertension and stage IV chronic kidney disease presented with a non-productive cough, dysphonia, and acute chest pain, revealing a mediastinal tumor on imaging. Physical examination showed no cervical tumors, and biochemical tests revealed elevated levels of total calcium and intact PTH, while serum phosphorus and calcitonin levels were normal. Imaging elucidated a parathyroid adenoma with mediastinal extension. Surgical intervention involved right parathyroidectomy, unveiling a 6 × 6 cm tumor with cystic and hemorrhagic degeneration, confirming the diagnosis of parathyroid apoplexy from a giant adenoma.&lt;br /&gt; &lt;b&gt;Conclusions&lt;/b&gt;: Giant parathyroid adenoma should be considered in patients presenting with a mediastinal mass and hypercalcemia. This condition can be complicated by parathyroid apoplexy in the context of PHPT. Timely imaging and surgical intervention are crucial for achieving optimal outcomes, with diagnosis confirmed through histopathology.

Bone Mineral Density and First Line Imaging with [18F]fluorocholine PET/CT in Normocalcemic and Hypercalcemic Primary Hyperparathyroidism: Results from a Single Center.

Objectives: Primary hyperparathyroidism (PHPT) is associated with normal or elevated calcium levels and affects bone mineral density. The proportion of cases predisposed to metabolic bone disease is unknown in patients with PHPT. The aim of this study was to assess bone mineral density and bone quality in patients with normo- or hypercalcemic primary hyperparathyroidism undergoing baseline parathyroid gland assessment with [18F]fluorocholine PET/CT imaging. Methods: A total of 140 consecutive patients were enrolled in this observational study. All patients with normo- or hypercalcemic primary hyperparathyroidism underwent dual-energy X-ray absorptiometry (DXA) for assessment of bone mineral density (BMD) and trabecular bone score (TBS). [18F]fluorocholine PET/CT was performed in all patients for the detection and localization of parathyroid adenoma. Hyper- and normocalcemic patients were compared with regard to the proportion of osteoporosis and osteopenia, T-Score, TBS, serum calcium, phosphorus and parathyroid hormone levels, the maximum standardized uptake value (SUVmax) in PET/CT imaging, and laboratory results. Results: The majority of patients was female (88.57%) and had a pathologic bone mineral density (52.86%). Overall, 33 patients had osteoporosis and 41 osteopenia. The mean lumbar T-Score was -1.48 (SD 1.37) and the T-Score of the femoral neck was -1.21 (SD 0.92). Mean TBS was also decreased (-2.13). No difference was found between normo- or hypercalcemic patients regarding bone metabolism and imaging parameters. Conclusions: More than half of patients with normo- or hypercalcemic PHPT showed abnormal BMD. First-line [18F]fluorocholine PET/CT identified parathyroid adenoma in a high proportion of patients, even in patients with normocalcemic PHPT. The early evaluation of metabolic bone disease seems desirable in clinical management of females with PHPT.

Coexisting parathyroid adenoma, thyroid carcinoma, and tuberculosis of thyroid: a case report

BackgroundCoexisting parathyroid adenoma, thyroid carcinoma, and tuberculosis of thyroid is a very rare phenomenon. Primary thyroid tuberculosis is itself very rare despite high global prevalence of tuberculosis in developing countries. Majority of thyroid tuberculosis identified in postoperative histopathology or cytopathology. The coexistence of thyroid cancer with tuberculosis or parathyroid adenoma has been reported in the literature but not a single case of the three pathologies coexisting together has been found in the literature published. We are presenting a rare case of a constellation of synchronous parathyroid adenoma, thyroid carcinoma, and thyroid tuberculosis. This case report will provoke researchers to work on understanding the association of hypercalcemia or chronic inflammation leading to development of malignancy or parathyroid adenoma in the presence of hypothyroidism will give future perspective in managing such patients.Case presentationA Islam lady aged 45 years old, diagnosed with hypothyroidism, was evaluated for pregnancy loss and rapid weight gain from 13 years back and started on tablets of levothyroxine 25 µg once daily. She was doing well until the past 2 years; there after she noticed insidious onset of a swelling over anterior aspect of right side of the neck and bone pain in back and lower limbs. Patient underwent routine investigations and was found to have raised serum calcium (11.4 mg/dl) and parathyroid hormone (253 pg/ml). Anti-thyroid peroxidase (TPO) and anti-thyroglobulin (Tg) level were normal. Ultrasounds showed multiple nodules in both lobe of thyroid and left inferior parathyroid adenoma. The patient underwent total thyroidectomy with left inferior parathyroidectomy, and final histopathology showed features of subacute granulomatous thyroiditis along with hurthle cell change in right lobe of thyroid. The left lobe additionally showed necrotizing epitheloid cell granulomas, which on Zeihl–Neelson staining revealed presence of acid-fast bacilli. Sections from the isthmus show a focus of papillary thyroid microcarcinoma. The left inferior parathyroid gland sent as a frozen sample was found to be parathyroid adenoma. On 6-month follow-up, the patient was feeling much relief in bone pain and tolerating antitubercular drugs uneventfully.ConclusionCoexistence of parathyroid adenoma, nonmedullary thyroid carcinoma, and thyroid tuberculosis is extremely rare. Surgery is curative for hyper parathyroidism and thyroid carcinoma. Thyroid tuberculosis responds well to current antitubercular drugs. Its etiology needs to be explored more; the probable hypothesis is chronic inflammation due to latent tuberculosis might leads to development of thyroid carcinoma and parathyroid adenoma. Further studies need to be done for better understanding of underlying mechanism and better management options for such patients. To the best of our knowledge, similar cases have not been reported.

Primary hyperparathyroidism with intrathyroidal location of parathyroid adenoma

Primary hyperparathyroidism is a common endocrine disease with high morbidity and mortality from all causes. The disease can be asymptomatic and for a long time remain undiagnosed, which leads to untimely surgical treatment, increases the risks of development and progression of severe disabling complications and worsens patients prognosis. In clinical practice there are certain difficulties in diagnosing this pathology. One of the urgent problems is the search for the source of parathyroid hormone hyperproduction, especially in case of atypical location of paraаdenoma. The most common atypical locations of altered parathyroid glands are thymus, retroor paraesophageal space, retropharyngeal space, mediastinum and thyroid gland. The frequency of intrathyroidal masses of parathyroid glands, in the thyroid parenchyma or under its capsule, ranges on average from 2 to 3%, but according to some authors can reach 18–22%. With such localization of paraadenomas there is a need for their differential diagnosis, first of all, with nodular formations of the thyroid gland. In addition, the absence of additional laboratory studies parathormone and calcium blood levels does not allow timely suspicion of the disease, and cytologic examination of the material obtained by fine-needle aspiration puncture biopsy does not allow reliable differentiation of the altered parathyroid gland. This article presents a clinical case of a patient with primary hyperparathyroidism with intrathyroidally located parathyroid adenoma, for a long time long identified as a “nodular goiter,” and provides a brief review of the methods that identify an intrathyroidally located parathyroma. Despite the abundance of diagnostic methods in visualization of intrathyroidal parathyroid glands, today the most appropriate seems to be expert ultrasound examination with assessment of the parathyroid hormone level in a washout after fine-needle aspiration, supplemented, if necessary, by scintigraphy and single-photon emission computed tomography combined with computed tomography or multispiral computed tomography.

Bone Disease in Primary Hyperparathyroidism-Changes Occurring in Bone Metabolism and New Potential Treatment Strategies.

Primary hyperparathyroidism (PHPT) is a common endocrinopathy, predominantly caused by a single parathyroid adenoma that is responsible for the excessive secretion of parathyroid hormone (PTH)-the hallmark of disease. Excess of this hormone causes remarkable changes in bone metabolism, including an increased level of bone remodeling with a predominance of bone resorption. Those changes lead to deterioration of bone structure and density, especially in cortical bone. The main treatment for PHPT is surgical removal of the adenoma, which normalizes PTH levels and terminates the progression of bone disease and leads to its regeneration. However, because not all the patients are suitable candidates for surgery, alternative therapies are needed. Current non-surgical treatments targeting bone disease secondary to PHPT include bisphosphonates and denosumab. Those antiresorptives prevent further bone loss, but they lack the ability to regenerate already degraded bone. There is ongoing research to find targeted drugs capable of halting resorption alongside stimulating bone formation. This review presents the advancements in understanding the molecular mechanisms responsible for bone disease in PHPT and assesses the efficacy of new potential therapeutic approaches (e.g., allosteric inhibitors of the PTH receptor, V-ATPase, or cathepsin inhibitors) aimed at mitigating bone loss and enhancing bone regeneration in affected patients.

Surgeon Review of 4D CT for Identification of Parathyroid Adenomas.

Preoperative localization of parathyroid adenomas aids surgical planning for patients with hyperparathyroidism. This study explores the diagnostic accuracy of surgeon-reviewed 4D computed tomography (4D CT) scans for localization of parathyroid adenomas. A retrospective review of 95 patients with hyperparathyroidism who underwent parathyroidectomy at a tertiary care center was performed. The sensitivity, specificity, positive and negative predictive values, accuracy of identifying abnormal glands by surgeon, and interrater reliability between two head and neck surgeons was assessed. The sensitivity of surgeon localization of all glands was 71% (95% CI, 63%-78%), improving to 76% when combined with radiology reads. The specificity was 98% (95% CI, 95%-99%), the positive predictive value was 95% (95% CI, 90%-99%), and the negative predictive value was 84% (95% CI, 79%-88%) for all abnormal glands. Interrater reliability between surgeons was κ = 0.771. The diagnostic accuracy of surgeon localization of abnormal glands on the 4D CT scan was substantial. Improvement with radiology report integration highlights the benefits of multidisciplinary collaboration. Interrater reliability between two fellowship-trained surgeons was moderate. These findings support the importance of surgeons developing proficiency in reading 4D CT scans to engage in interdisciplinary communication and improve patient outcomes.