Parathyroid Adenoma Research Articles

Acute Pancreatitis Caused by Hypercalcemia as an Initial Manifestation of Primary Hyperparathyroidism (PHPT): A Rare Case Report

Acute pancreatitis (AP) is a frequent gastrointestinal emergency with gallstones and chronic alcohol consumption being the most common causes. Other etiologies can also be identified such as hypercalcemia, which remains a rare yet deadly cause of acute pancreatitis. In this case, hypercalcemia is usually the result of hyperparathyroidism. The latter’s causative diseases must be investigated carefully. Herein, we report the case of AP related to hypercalcemia from a parathyroid adenoma. By reporting this case and reviewing the literature, we aim to raise the practitioners’ attention to this association as it is crucial for timely diagnosis and appropriate management of these cases.

Video-Assisted Thoracoscopic Surgery Is a Safe and Feasible Technique for Mediastinal Parathyroid Lesions.

Introduction: Hyperfunctional ectopic parathyroid glands in the mediastinum pose a challenge to diagnosis and require optimal surgical management. Video-assisted thoracoscopic surgery (VATS) has emerged as a promising minimally invasive approach, offering potential benefits in terms of both patient comfort and oncological principles. This study aimed to evaluate the effectiveness and safety of VATS for the treatment of hyperfunctional ectopic parathyroid glands in the mediastinum. Methods: Among the 538 patients with mediastinal tumors who underwent thoracoscopic surgery at Istanbul University (2008-2021), 11 exhibited hyperfunctional ectopic parathyroid glands. The localization of the glands was performed using various diagnostic techniques, including neck ultrasound, sestamibi scan, CT (computerized tomography), and SPECT (Single-photon emission computed tomography). VATS (Video-assisted thoracoscopic surgery) was used to remove ectopic parathyroid glands in all 11 patients, with no need for conversion to open surgery. Results: The pathological results showed that VATS successfully removed the ectopic glands in all 11 patients. Serum parathyroid hormone (PTH) levels were monitored intraoperatively, and frozen sections were used to confirm the presence of parathyroid adenomas in all cases. Postoperative analysis showed that PTH levels dropped by at least 50% within 10-15 minutes after adenoma removal. Conclusion: VATS is a safe and effective method for the treatment of hyperfunctional ectopic parathyroid glands in the mediastinum with a low risk of complications.

Study of Multimodality Imaging Features of Brown Tumor or Osteitis Fibrosa Cystica

Introduction Brown tumor, also known as osteitis fibrosa cystica, is a rare but significant manifestation of hyperparathyroidism characterized by focal bone lesions resulting from excessive osteoclastic activity. Despite its rarity, Brown tumor poses diagnostic challenges due to its varied clinical presentations and radiographic features, often mimicking other bone lesions such as giant cell tumors or metastatic disease. Material and Methods In this study, we present a retrospective analysis of 6 cases of Brown tumor diagnosed and managed at our institution over a 12 months period from April 2022 to April 2023. Our objectives are to delineate the diverse clinical manifestations of Brown tumor, discuss diagnostic modalities utilized, treatment strategies employed, and evaluate patient outcomes. Results Five out of our six patients were females. Also 5 out of our 6 patients were under the age of 25. 2 patients presented to us with multiple lytic lesions and other 4 patients had solitary lesions. 1 patient out of 6 presented to us with pathological fracture. Only 2 out of the 6 patients had a positive sestamibi scan but Ultrasonography (USG) of the neck and MRI of the neck showed the presence of parathyroid adenoma in all the cases. Preoperative average of VAS score in this patients was 67 which was decreased to as low as 24. We performed paired t-tests on the blood investigation values and Visual Analog Scale (VAS) scores for all patients. The results were statistically significant, with values returning to normal three months post-surgery. Conclusion When radiographic evidence of a lytic lesion and hypercalcemia are present, Brown tumor should always be considered in the differential diagnosis. Brown tumor has a distinctive imaging appearance, with solid components displaying intermediate to low intensity on T1- and T2-weighted images, while the cystic components appear hyperintense on T2-weighted images and exhibit fluid-fluid levels. MRI of the neck corroborates the ultrasound findings and detects parathyroid adenomas as hyperintense nodes on T2-weighted images. Parathyroidectomy yields excellent results, enabling conservative management of lytic lesions.

Incidental synchronous intrathyroidal parathyroid carcinomas and papillary thyroid microcarcinoma with compressive neck mass and primary hyperparathyroidism: case report and literature review

BackgroundParathyroid carcinoma (PC) is a rare malignancy, often diagnosed incidentally through postoperative pathological examination. The occurrence of nodular goiter, intrathyroidal parathyroid carcinoma, contralateral parathyroid adenoma (PA), and papillary thyroid microcarcinoma (PTMC) is extremely uncommon, which prompted us to report our case experience.Case presentationWe describe a 67-year-old male who presented with a cervical mass causing tracheal compression, which prompted him to seek medical advice. Based on preoperative auxiliary examination results from color Doppler ultrasound, SPECT parathyroid imaging, and blood tests, he was initially diagnosed with a suspected parathyroid adenoma and nodular goiter. Excision of the right lobe and isthmus of the thyroid, and left superior parathyroid gland was conducted, which were sent to intraoperative frozen pathological examination. During intraoperative observation, adhesion around the right thyroid lobe was discovered. Consequently, right central area lymph node dissection was performed due to suspicion of an aggressive malignant tumor. Histology and immunohistochemistry analysis revealed incidental intrathyroidal parathyroid carcinoma, contralateral parathyroid adenoma, classical papillary thyroid microcarcinoma, and nodular goiter.ConclusionParathyroid carcinoma should be highly suspected when extremely high levels of PTH and severe hypercalcemia are present, which cannot be simply explained by a preoperatively localized parathyroid adenoma, especially when suspicious malignant adhesion is found during intraoperative exploration. In cases where multifocal thyroid nodules are associated with increased uptake of 99Tc-sestamibi, the possibility of coexisting carcinomas should be considered, not only for thyroid malignancy but also for the potential presence of intrathyroidal parathyroid carcinoma.

A Comparative Genomic Analysis of Parathyroid Adenomas and Carcinomas Harboring Heterozygous Germline CDC73 Mutations.

Parathyroid cancer has been linked to germline mutations of the CDC73 gene. However, carriers harboring cancer-associated germline CDC73 mutations may develop only parathyroid adenoma or no parathyroid disease. This incomplete penetrance indicates that additional genomic events are required for parathyroid tumorigenesis. (1) Determine the status of the second CDC73 allele in parathyroid tumors harboring germline CDC73 mutations, and (2) compare the genomic landscapes between parathyroid carcinomas and adenomas. Whole-exome and RNA sequencing of 12 parathyroid tumors harboring germline CDC73 mutations (6 adenomas and 6 carcinomas) and their matched normal tissues. All 12 parathyroid tumors had gained one somatic event predicted to cause a complete inactivation of the second CDC73 allele. Several distinctive genomic features were identified in parathyroid carcinomas compared to adenomas, including more single nucleotide variants bearing the C>G transversion and APOBEC deamination signatures, frequent mutations of the genes involved in the PI-3K/mTOR signaling, a greater number of copy number variations, and substantially more genes with altered expression. Parathyroid carcinomas also share some genomic features with adenomas. For instance, both have recurrent somatic mutations and copy number loss that impact the genes involved in T-cell receptor signaling and tumor antigen presentation, suggesting a shared strategy to evade immune surveillance. Biallelic inactivation of CDC73 is essential for parathyroid tumorigenesis in carriers harboring germline mutations of this gene. Despite sharing some genomic features with adenomas, parathyroid carcinomas have more distinctive alterations in the genome, some of which may be critical for cancer formation.

Intrathyroidal Parathyroid Adenoma - An Incidental Diagnosis.

Aim This case report highlights the importance of preoperative assessment of calcium in all cases of thyroid surgery. Intrathyroidal parathyroid adenoma (IPA) is a rare presentation of primary hyperparathyroidism. It is caused by abnormal embryonic migration of parathyroid glands and is difficult to detect preoperatively. When diagnosed pre operatively it has good surgical outcome. Herein authors present a case of thirty-two-year lady who underwent hemithyroidectomy for colloid goitre and was detected to have intrathyroidal parathyroid adenoma (IPA) on histopathological examination.

Parathyroid Adenoma Orientation for Gland Embryologic Origin on Ultrasonography

Accurate preoperative localization is critical to success in targeted parathyroidectomy for primary hyperparathyroidism. To determine if the association between the long axis of a parathyroid adenoma (PTA) candidate and strap musculature on sagittal ultrasonography (US) can be used to predict the embryologic origin of the gland. This diagnostic study was performed using the Stanford Research Repository. Patients 18 years or older with primary hyperparathyroidism who underwent parathyroidectomy between January 2009 and October 2021 were considered. Additional inclusion criteria were having clear sagittal view of the adenoma candidate on US, confirmation of the gland of origin intraoperatively, and confirmation of hypercellular parathyroid on final pathology. Data were analyzed from October 2021 to June 2022. B-mode US and surgical parathyroidectomy. The index test was using US to measure the angle between the long axis of an adenoma candidate and the strap musculature in the sagittal plane. This angle was used to test whether inferior and superior PTAs could be accurately assigned. The hypothesis was formulated prior to data collection. A total of 426 patients (mean [range] age, 61.1 [20-96] years; 316 [74.2%] female) with 442 adenomas met inclusion criteria. Of the 442 adenomas, 314 (71.0%) had measurable angles, of which 204 (46.2%) were assigned a superior origin, 238 (53.8%) were assigned an inferior origin, and 128 (29%) were indeterminate. Of the surgically identified superior PTAs, 144 (70.6%) had a definable angle, and of the surgically identified inferior PTAs, 170 (71.4%) had a definable angle. The receiver operating characteristic analysis found 94° as the optimized angle for differentiating true negatives from true positives, with an overall sensitivity of 74% and specificity of 72%. This supported using 90° as a break point for US review. True positives were considered superior adenomas with an angle greater than 90°; true negatives were inferior adenomas with an angle less than 90°. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of angulation analysis for determining PTA origin were 72.2% (95% CI, 64.9%-79.5%), 73.5% (95% CI, 66.9%-80.1%), 69.8% (95% CI, 62.5%-77.1%), 75.8% (95% CI, 69.3%-82.3%), and 72.9%, respectively. A subgroup analysis of 426 adenomas using the posterior carotid artery border on transverse US as a surrogate for predicting gland origin showed the following for sensitivity, specificity, positive predictive value, negative predictive value, and accuracy: 49.5% (95% CI, 42.6%-56.4%), 82.3% (95% CI, 77.3%-87.3%), 71.4% (95% CI, 63.9%-78.9%), 64.6% (95% CI, 59.1%-70.1%), and 66.9%, respectively. This diagnostic study showed that PTA angulation on sagittal plane US can be used to predict gland of origin and guide surgery. The relationship between adenoma and posterior carotid artery border on transverse US can also be used to predict gland origin. These easy-to-apply US-based tests can be used in conjunction with other imaging modalities to guide targeted parathyroidectomy.

Differentiating Superior and Inferior Parathyroid Adenomas—A Novel Ultrasonography-Based Approach

Differentiating Superior and Inferior Parathyroid Adenomas—A Novel Ultrasonography-Based Approach

Delayed Diagnosis and Late Presentation of Primary Hyperparathyroidism in Somalia: A Case Report and Literature Review

Primary hyperparathyroidism (PHPT) is a rare endocrine disorder characterized by elevated serum calcium levels due to overproduction of parathyroid hormone (PTH). While parathyroid adenomas are the most common cause, they can present diagnostic and management challenges, especially in resource-limited settings. We present the case of a 51-year-old Somali female with a six-year history of generalized weakness, fatigue, and nonspecific abdominal pain. Laboratory investigations revealed elevated PTH levels (231 ng/ml) and hypercalcemia (14 mg/dl), consistent with PHPT. Cervical ultrasound identified a hypoechoic hypervascular solitary lesion suggestive of a parathyroid adenoma. The patient underwent a successful parathyroidectomy, resulting in the normalization of serum calcium levels and symptomatic relief. Histopathological examination confirmed the diagnosis of parathyroid adenoma. This case underscores the importance of early recognition and intervention in PHPT, particularly in underserved regions where healthcare resources may be limited. Efforts to raise awareness, provide training for healthcare workers, and improve access to diagnostic and treatment modalities are crucial in optimizing outcomes for patients with PHPT.

Sporadic Parathyroid Adenoma: A Pilot Study of Novel Biomarkers in Females.

Background and Objectives: Parathyroid adenoma is a distinct cause of primary hyperparathyroidism, with the vast majority being sporadic ones. Proteomic analysis of parathyroid adenomas has proposed a large number of related proteins. The aim of this study is to evaluate the immunohistochemical staining of ANXA2, MED12, MAPK1 and VDR in parathyroid adenoma tissue. Materials and Methods: Fifty-one parathyroid adenomas were analyzed for ANXA2, MED12, MAPK1 and VDR expressions. Tissue was extracted from formalin-fixed paraffin-embedded parathyroid adenoma specimens; an immunohistochemical study was applied, and the percentage of allocation and intensity were evaluated. Results: ANXA2 stained positively in 60.8% of all cell types, while MED12 had positive staining in 66%. MAPK1 expression was found to be negative in total, although a specific pattern for oxyphil cells was observed, as they stained positive in 17.7%. Finally, VDR staining was positive at 22.8%, based on nuclear staining. Conclusions: These immunohistochemical results could be utilized as biomarkers for the diagnosis of sporadic parathyroid adenoma. It is of great importance that a distinct immunophenotype of nodule-forming cells in a positive adenoma could suggest a specific pattern of adenoma development, as in hereditary patterns.

Evaluation of Focused Mini-Incision Parathyroidectomy in Primary Hyperparathyroidism

Abstract Background In the era of effective preoperative localization and availability of intraoperative parathyroid hormone (IOPTH) assay, the trend now in parathyroidectomy is shifting from bilateral neck exploration (BNE) into minimal invasive parathyroidectomy (MIP). The concept of MIP is based on the fact that 85% of cases have single adenoma. This study highlights the outcomes of focused mini- incision parathyroidectomy (FMIP) for the treatment of selected cases of primary hyperparathyroidism. Aim of study: To evaluate and assess the outcome and advantages of focused mini-incision parathyroidectomy in parathyroid adenoma of primary hyperparathyroidism. Patients and Methods This cohort study was conducted at endocrine surgery unit, Ain Shams University Hospital, and Sohag Cancer Institute including 22 patients with benign solitary parathyroid adenoma; 17 retrospective cases & 5 prospective cases. These included patients had been operated with focused mini-incision parathyroidectomy within the time period from January 2018 to December 2020 as retrospective cases and from January 2021 to December 2021 as prospective cases. Results In this study, age ranged from 30 to 70 years with mean age 50.23 ± 10.71 years. The preoperative serum calcium level ranged from 10.8 to 14.2 mg/dl (mean 12.28 ± 1.16 mg/dl). The preoperative parathyroid hormone level was elevated ranging from 256 to 2090 pg/mL (mean 970.68 ± 563.97 pg/mL). In this study, the operative time ranged from 55 to 75 minutes with mean 64.36 ± 6.33 minutes, percentage of IOPTH decrease level ranged from 75-95 % with mean percentage 85.72 ± 6.28 %. There were no cases with intraoperative bleeding or recurrent laryngeal nerve (RLN) injury. Hospital stay ranged from 6-16 days with mean 10.77 ± 3.10 days. There is no wound infection in all cases. All cases reached a success rate up to 100% (decrease the IOPTH level ≥ 75 %, and resolution of preoperative hypercalcemic manifestations). Conclusion Depending to the high successful rate, very low intraoperative morbidity and better postoperative recovery and cosmoses of FMIP technique, it should be the first choice for pHPT cases with solitary parathyroid adenoma, provided by the concordance localization study of U/S and MIBI scan preoperative.

Dual concentric echo sign of ultrasound in primary hyperparathyroidism: The clinical and histopathologic features and differentiation from lymph nodes

ContextUltrasound (US) is the most economical and widely used method for detecting lesions in parathyroid regions. Identifying typically parathyroid adenomas as hypoechoic nodules with clear margins. However, 10 % of lesions exhibit atypical features, such as the dual concentric sign, and the cognition of them still needs to be improved. ObjectiveTo promote understanding of clinical and histopathological features for parathyroid lesions with the dual concentric echo sign and to investigate its pathogenesis and methods for distinguishing from cervical lymph nodes to improve US diagnostic accuracy. MethodsRetrospectively, patients were categorized into three groups: Group 1, with 36 patients showing parathyroid lesions with dual concentric echo signs; Group 2, with 40 patients displaying classic hypoechoic parathyroid lesions; and Group 3, comprising 36 patients with identified lymph nodes, which were all examined from January 2018 to December 2019. The clinical data on demographics, clinical symptoms, serum levels, histopathologic findings, and US image characteristics were thoroughly reviewed. ResultsAccording to the clinical data, no significant differences in demographics or lesion sizes were observed in Group 1 and Group 2 (p > 0.05). No significant variances were noted in biochemical markers, including PTH, T-25OHD, and ALP. However, a notable difference was identified in adjusted serum calcium levels, which were significantly lower in Group 1 compared to Group 2 (p < 0.05). Additionally, the proportion of asymptomatic patients was significantly higher in Group 1 compared to Group 2 (p < 0.05). Pathological examination revealed that all lesions with dual concentric echo signs were parathyroid adenomas. The isoechoic central region predominantly corresponded to areas of loose edema, while the hypoechoic peripheral layer was primarily associated with chief and/or oncocytic cells. By comparing the ultrasonography of Groups 1 and 3, the parathyroid lesions with dual concentric echo signs exhibited significant distinctions from lymph nodes in size, blood flow classification, vascular distribution, and anatomical location (p < 0.05). ConclusionThe parathyroid lesions with dual concentric echo signs in US corresponded to specific histopathological manifestations and relatively mild clinical features in the patients, this finding may increase the likelihood of incidental detection of parathyroid lesions by US. Attention to the details of size, location, and blood flow, especially, may aid US physicians in differentiating parathyroid adenomas from cervical lymph nodes.

Gasless transoral endoscopic thyroidectomy in a primary substernal goitre patient: First case.

For most primary substernal goitre (SG) surgeries, sternotomy is required because the blood supply vessels of tumours come from the mediastinum. However, sternal dehiscence may lead to several surgical complications. We reported an older patient who underwent simultaneous removal of a primary SG and parathyroid adenoma through a gasless transoral endoscopic approach. The patient recovered well with no hoarseness, post-operative bleeding or other complications after the operation. To the best of our knowledge, this is the first reported case of gasless transoral endoscopic parathyroid adenoma and primary SG resection in the real world. We found that gasless transoral endoscopic surgery is feasible in patients with small primary SG and parathyroid adenoma.

Multiple pathological fractures with a hidden aetiology

Bone disease is a well-recognised complication of primary hyperparathyroidism (PHPT). With early diagnosis of PHPT, florid bony changes such as brown tumours, lytic lesions and pathological fractures are rarely seen now. Here, we report an unusual presentation of PHPT in the current era. A 47-year-old lady was evaluated for multiple fragility fractures. Biochemical assessment confirmed primary hyperparathyroidism. DEXA scan showed severe osteoporosis. Left parathyroid adenoma was localised with imaging. She had multiple brown tumours. She underwent parathyroid adenoma excision and recovered after surgery with improved quality of life. Proper evaluation for secondary causes of osteoporosis is vital especially in premenopausal women. Early diagnosis and treatment of PHPT prevent disastrous complications.

Assessment of Vitamin D Status in Primary Hyperparathyroidism Patients: A Retrospective Study.

Primary hyperparathyroidism (PHPT), a condition that manifests in various clinical forms, is a significant health concern. Normocalcemic primary hyperparathyroidism (NPHPT) is characterized by normal calcemia despite elevated parathyroid hormone (PTH) levels. Vitamin D deficiency can contribute to the clinical spectrum and complexity of NPHPT. Low vitamin D levels can elevate PTH, making it difficult to distinguish between NPHPT and secondary hyperparathyroidism. Additionally, it might mask hypercalcemia, leading to an underestimation of the disease severity.Our study aims to shed light on these complexities by investigating normocalcemic and hypercalcemic PHPT patient's clinical, hormonal, and biochemical patterns, including their vitamin D status. Materials: In this retrospective study, we enrolled 60 PHPT patients with autonomous parathyroid function confirmed using a combination of ultrasonography, radionuclide scan, and parathyroid function index calculation. We evaluated the albumin-corrected calcemia, calciuria, PTH, 25(OH)D level, serum phosphate, bone mineral density, and major clinical symptoms (fracture, nephrolithiasis). A comparative analysis and a correlation study were performed between normo- and hypercalcemic and vitamin D-deficient and vitamin D-non-deficient groups. The median age was 62 years, 51.66% (31/60) being normocalcemic and 46.66% (29/60) presenting a deficient 25(OH)D level. In the group with 25(OH)D below 20 ng/mL, we observed a reduced level of albumin-corrected calcemia, without a significant increase of PTH compared to the adequate 25(OH)D level group. The frequency of the NPHPT and the risk of fracture were significantly higher in the deficient 25(OH)D group (20/60, 33.33%and8/60, 13.33%) than in the adequate one (11/60, 18.33% and 1/60, 1.66%) with OR=4.7 (p<0.004) and OR=9.7 (p<0.027), respectively. We also found a positive correlation between PTH and adenoma size, the parathyroid function index and adenoma size, as well as PTH and phosphate levels. However, the correlation between 25(OH)D and phosphate levels was negative and moderate (rho=-0.504, p<0.001), adding a new layer of complexity to our understanding of these relationships. Our study provided significant insight into the link between vitamin D status and normocalcemic PHPT. We found that vitamin D-deficient patients with normocalcemic PHPT have an increased fracture risk, which requires meticulous monitoring and possible supplementation with vitamin D. This should be done carefully to avoid exacerbating hypercalcemia or hypercalciuria. Further research is needed to refine these management strategies and deepen our understanding of the complex relationships between the analyzed parameters.

1064 Cystic Parathyroid Adenoma: A Rare Occurrence in Setting of Stage IV Chronic Kidney Disease with Tertiary Hyperparathyroidism

1064 Cystic Parathyroid Adenoma: A Rare Occurrence in Setting of Stage IV Chronic Kidney Disease with Tertiary Hyperparathyroidism

434 Determining the Utility of Early Phase [99mTc]Tc-MIBI Single-Photon Emission Computed Tomography with Contrast Enhanced Computerised tomography(SPECT/CECT) in Localisation of Parathyroid Adenomas for Surgical Planning

434 Determining the Utility of Early Phase [99mTc]Tc-MIBI Single-Photon Emission Computed Tomography with Contrast Enhanced Computerised tomography(SPECT/CECT) in Localisation of Parathyroid Adenomas for Surgical Planning

Dual-tracer subtraction scintigraphy combined with SPECT/CT in preoperative patients with primary hyperparathyroidism.

Abstract.

Utility of using Indocyanine green to locate parathyroid adenoma and predict hypocalcemia

Introduction: Secondary hypocalcemia due to hypoparathyroidism is a frequent complication of parathyroidectomy, which has certain difficulties in terms of intraoperative localization of the gland, since the surgeon uses his sight, touch and experience, to reach the task of the surgical act. Clinical case: 62-year-old woman, who started her current condition 8 months ago when she was diagnosed with osteoporosis, with hypercalcemia and significant elevation of parathyroid hormone. Cervical ultrasound and 99mTc-MIBI scintigraphy were requested, showing a nodular image compatible with parathyroid adenoma in the left lower thyroid lobe. The patient underwent left inferior parathyroidectomy with the use of indocyanine green. Conclusion: The identification of a parathyroid adenoma intraoperatively with the aid of fluorescence appears to be a reproducible, safe and easy way to use when treating this type of endocrine pathology.

Avascular Necrosis of Femoral Head in Bone Scintigraphy with Concurrent Parathyroid Adenoma Diagnosed by Parathyroid SPECT/CT- A Case Report

Avascular Necrosis of Femoral Head in Bone Scintigraphy with Concurrent Parathyroid Adenoma Diagnosed by Parathyroid SPECT/CT- A Case Report