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Juhlin CC. The road ahead: a brief guide to navigating the 2022 WHO classification of endocrine and neuroendocrine tumours. J Clin Pathol 2024:jcp-2023-209060. [PMID: 38981664 DOI: 10.1136/jcp-2023-209060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/20/2024] [Indexed: 07/11/2024]
Abstract
The most recent WHO classification of endocrine and neuroendocrine tumours has brought about significant changes in the diagnosis and grading of these lesions. For instance, pathologists now have the ability to stratify subsets of thyroid and adrenal neoplasms using various histological features and composite risk assessment models. Moreover, novel recommendations on how to approach endocrine neoplasia involve additional immunohistochemical analyses, and the recognition and implementation of these key markers is essential for modernising diagnostic capabilities. Additionally, an improved understanding of tumour origin has led to the renaming of several entities, resulting in the emergence of terminology not yet universally recognised. The adjustments in nomenclature and prognostication may pose a challenge for the clinical team, and care providers might be eager to engage in a dialogue with the diagnosing pathologist, as treatment guidelines have not fully caught up with these recent changes. Therefore, it is crucial for a surgical pathologist to be aware of the knowledge behind the implementation of changes in the WHO classification scheme. This review article will delve into the most significant diagnostic and prognostic changes related to lesions in the parathyroid, thyroid, adrenal glands and the gastroenteropancreatic neuroendocrine system. Additionally, the author will briefly share his personal reflections on the clinical implementation, drawing from a couple of years of experience with these new algorithms.
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Affiliation(s)
- Carl Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
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Ohkuwa K, Katoh R, Sugino K, Nagahama M, Kitagawa W, Matsuzu K, Fukunari N, Ito K. Evaluation of factors predicting postoperative recurrence and metastasis of parathyroid cancer: a single-center study. World J Surg Oncol 2023; 21:32. [PMID: 36737774 PMCID: PMC9896802 DOI: 10.1186/s12957-023-02912-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The purpose of this study was to examine the postoperative clinical course of parathyroid carcinoma to determine factors that predict postoperative recurrence and distant metastasis. METHODS In this retrospective study, we included 38 patients with parathyroid carcinoma who received surgical intervention at Itoh Hospital between 1979 and 2020. Clinicopathologic characteristics (age, sex, intact PTH, serum Ca level, operation type, parathyroid weight, parathyroid size, histopathologic findings: vascular invasion, capsular invasion, necrosis, histological type, and Ki-67 staining) were used. The median follow-up observation period was 63.7 months. RESULTS Postoperatively, 5 patients (13.2%) developed distant metastasis or had localized recurrence, and 3 patients died (7.9%). The results of the univariate analysis revealed three factors affecting distant metastasis and recurrence, which were Ki-67 (p = 0.0041), the presence or absence of necrosis (p = 0.0163), and tumor weight (p = 00,189). Using the cutoff values obtained by ROC analysis, which were 4.1 for Ki-67 (sensitivity of 80% and specificity of 96.9%) and 4890 mg for tumor weight (sensitivity of 100% and specificity of 60.9%), we calculated the cumulative incidence of recurrence and distant metastasis by the three factors retained. We found that the presence of the three factors was associated with a high possibility of distant metastasis or recurrence during the 5-year follow-up period. CONCLUSIONS Three factors, Ki-67, necrosis, and tumor weight in parathyroid carcinoma, may predict outcomes of postoperative recurrence and distant metastasis.
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Affiliation(s)
- Keiko Ohkuwa
- grid.482675.a0000 0004 1768 957XDepartment of Surgery and Thyroid Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan ,grid.414857.b0000 0004 7685 4774Department of Surgery, Ito Hospital, Tokyo, 150-8308 Japan
| | - Ryohei Katoh
- grid.414857.b0000 0004 7685 4774Department of Pathology, Ito Hospital, Tokyo, Japan
| | - Kiminori Sugino
- grid.414857.b0000 0004 7685 4774Department of Surgery, Ito Hospital, Tokyo, 150-8308 Japan
| | - Mitsuji Nagahama
- grid.414857.b0000 0004 7685 4774Department of Surgery, Ito Hospital, Tokyo, 150-8308 Japan
| | - Wataru Kitagawa
- grid.414857.b0000 0004 7685 4774Department of Surgery, Ito Hospital, Tokyo, 150-8308 Japan
| | - Kenichi Matsuzu
- grid.414857.b0000 0004 7685 4774Department of Surgery, Ito Hospital, Tokyo, 150-8308 Japan
| | - Nobuhiro Fukunari
- grid.482675.a0000 0004 1768 957XDepartment of Surgery and Thyroid Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Koichi Ito
- grid.414857.b0000 0004 7685 4774Department of Surgery, Ito Hospital, Tokyo, 150-8308 Japan
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Erickson LA, Mete O, Juhlin CC, Perren A, Gill AJ. Overview of the 2022 WHO Classification of Parathyroid Tumors. Endocr Pathol 2022; 33:64-89. [PMID: 35175514 DOI: 10.1007/s12022-022-09709-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2022] [Indexed: 12/18/2022]
Abstract
The 2022 WHO classification reflects increases in the knowledge of the underlying pathogenesis of parathyroid disease. In addition to the classic characteristic features of parathyroid neoplasms, subtleties in histologic features which may indicate an underlying genetic abnormality reflect increased understanding of the clinical manifestations, histologic, and genetic correlation in parathyroid disease. The importance of underlying genetic aberrancies is emphasized due to their significance to the care of the patient. Traditionally, the term "parathyroid hyperplasia" has been applied to multiglandular parathyroid disease; however, the concept of hyperplasia is generally no longer supported in the context of primary hyperparathyroidism since affected glands are usually composed of multiple "clonal" neoplastic proliferations. In light of these findings and management implications for patient care, the 2022 WHO classification endorses primary hyperparathyroidism-related multiglandular parathyroid disease (multiglandular multiple parathyroid adenomas) as a germline susceptibility-driven multiglandular parathyroid neoplasia. From such a perspective, pathologists can provide additional value to genetic triaging by recognizing morphological and immunohistochemical harbingers of MEN1, CDKN1B, MAX, and CDC73-related manifestations. In the current WHO classification, the term "parathyroid hyperplasia" is now used primarily in the setting of secondary hyperplasia which is most often caused by chronic renal failure. In addition to expansion in the histological features, including those that may be suggestive of an underlying genetic abnormality, there are additional nomenclature changes in the 2022 WHO classification reflecting increased understanding of the underlying pathogenesis of parathyroid disease. The new classification no longer endorses the use of "atypical parathyroid adenoma". This entity is now being replaced with the term of "atypical parathyroid tumor" to reflect a parathyroid neoplasm of uncertain malignant potential. The differential diagnoses of atypical parathyroid tumor are discussed along with the details of worrisome clinical and laboratory findings, and also features that define atypical histological and immunohistochemical findings to qualify for this diagnosis. The histological definition of parathyroid carcinoma still requires one of the following findings: (i) angioinvasion (vascular invasion) characterized by tumor invading through a vessel wall and associated thrombus, or intravascular tumor cells admixed with thrombus, (ii) lymphatic invasion, (iii) perineural (intraneural) invasion, (iv) local malignant invasion into adjacent anatomic structures, or (v) histologically/cytologically documented metastatic disease. In parathyroid carcinomas, the documentation of mitotic activity (e.g., mitoses per 10mm2) and Ki67 labeling index is recommended. Furthermore, the importance of complete submission of parathyroidectomy specimens for microscopic examination, and the crucial role of multiple levels along with ancillary biomarkers have expanded the diagnostic workup of atypical parathyroid tumors and parathyroid carcinoma to ensure accurate characterization of parathyroid neoplasms. The concept of parafibromin deficiency has been expanded upon and term "parafibromin deficient parathyroid neoplasm" is applied to a parathyroid neoplasm showing complete absence of nuclear parafibromin immunoreactivity. Nucleolar loss is considered as abnormal finding that requires further molecular testing to confirm its biological significance. The 2022 WHO classification emphasizes the role of molecular immunohistochemistry in parathyroid disease. By adopting a question-answer framework, this review highlights advances in knowledge of histological features, ancillary studies, and associated genetic findings that increase the understanding of the underlying pathogenesis of parathyroid disease that are now reflected in the updated classification and new entities in the 2022 WHO classification.
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Affiliation(s)
- Lori A Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First St SW, Rochester, MN, 55901, USA.
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - C Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Anthony J Gill
- Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia
- Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
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Giant parathyroid tumours in primary hyperparathyroidism: a systematic review. Langenbecks Arch Surg 2022; 407:501-516. [PMID: 35039921 DOI: 10.1007/s00423-021-02406-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Giant parathyroid adenoma (GPA) can present with severe biochemical derangement similar to the clinical presentation of parathyroid carcinoma (PC). This study aims to present the current evidence on surgical management of GPAs in primary hyperparathyroidism. METHODS A systematic review of the literature on GPAs was conducted following the PRISMA guidelines. Data on clinical, biochemical, preoperative diagnostic, and surgical methods were analysed. RESULTS Sixty-one eligible studies were included reporting on 65 GPAs in eutopic, ectopic mediastinal, and intrathyroidal locations (61.5%, 30.8%, and 7.7%, respectively). A palpable neck mass was present in 58% of GPAs. A total of 90% of patients had symptoms including fatigue, skeletal pain, pathological fracture, nausea, and abdominal pain. Ninety percent of patients had significant hypercalcaemia (mean 3.51 mmol/L; range: 2.59-5.74 mmol/L) and hyperparathyroidism with PTH levels on average 14 times above the upper limit of the normal reference. There was no correlation between the reported GPA size and PTH nor between GPA weight and PTH (p = 0.892 and p = 0.363, respectively). Twenty-four percent had a concurrent thyroidectomy for suspicious features, intrathyroidal location of GPA, or large goitre. Immunohistochemistry such as Ki-67, parafibromin, and galectin-3 was used in 18.5% of cases with equivocal histology. Ninety-five percent of GPAs were benign with 5% reported as atypical adenomas. CONCLUSION The reported data on GPAs are sparse and heterogeneous. In GPAs with suspicious features for malignancy, en bloc resection with concurrent thyroidectomy may be considered. In the presence of equivocal histological features, ancillary immunohistochemistry is advocated to differentiate GPAs from atypical adenomas and PCs.
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De Pasquale L, Bulfamante AM, Felisati G, Castellani L, Ghilardi G, Saibene AM. Management and Outcome of Parathyroid Carcinoma-Induced Primary Hyperparathyroidism: A Single-Centre Experience. Int J Endocrinol 2021; 2021:5397941. [PMID: 34659402 PMCID: PMC8516565 DOI: 10.1155/2021/5397941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Parathyroid carcinoma (PC) is the rarest endocrine cancer and an infrequent cause of primary hyperparathyroidism (PHPT), responsible for less than 1% of cases. Due to its rarity, treatment is challenging. METHODS A retrospective cohort study on 462 patients referred for parathyroidectomy to Thyroid and Parathyroid Unit at Santi Paolo e Carlo Hospital, Milan, Italy, from 2011 to 2021. We identified and individually described the patients affected with PC. Then, we split all patients treated for PHPT into four groups based on the cause: PC, adenoma, atypical adenoma, and hyperplasia. Patients' demographics, preoperative evaluation results, intraoperative findings, and outcomes for the PC group were compared with groups of PHPT due to benign causes. RESULTS Eight cases of PC were identified, five males and three females. Seven cases presented with symptoms of hypercalcemia and one with a neck mass. Five underwent en bloc resections and three local excisions. Histopathological features showed capsular invasion in four patients, capsular and soft tissue invasion in three patients, and vascular invasion in one case. No patients had distant metastasis. One patient was classed as high risk based on the Schulte classification system. All patients treated for PC were alive and disease-free at a mean follow-up of 38.4 months. When compared with other PHPT patients, PC patients were more frequently male and had higher preoperative blood calcium and PTH and lower phosphate levels, larger and heavier parathyroids excised, lower postoperative calcium, and a higher rate of postoperative hypoparathyroidism. CONCLUSION Our study highlights some aspects valuable to suspect PC and differentiate PHPT-PC from benign causes of PHPT preoperatively. Preoperative suspicion of malignancy is essential to guarantee the best course of treatment for patients. Although limited for size and follow-up, the excellent outcome of our series seems to support the value of both surgery extension and risk class according to the Schulte classification as possible prognostic factors for recurrence.
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Affiliation(s)
- Loredana De Pasquale
- Thyroid and Parathyroid Surgery Service-Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì 8, 20142 Milan, Italy
| | - Antonio Mario Bulfamante
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì 8, 20142 Milan, Italy
| | - Giovanni Felisati
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì 8, 20142 Milan, Italy
| | - Luca Castellani
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì 8, 20142 Milan, Italy
| | - Giorgio Ghilardi
- Department of Health Sciences, Clinica Chirurgica Generale, Università Degli Studi di Milano, Via Antonio di Rudinì 8, 20142 Milan, Italy
| | - Alberto Maria Saibene
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì 8, 20142 Milan, Italy
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Davies MP, John Evans TW, Tahir F, Balasubramanian SP. Parathyroid cancer: A systematic review of diagnostic biomarkers. Surgeon 2021; 19:e536-e548. [PMID: 33642204 DOI: 10.1016/j.surge.2021.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Parathyroid cancers are rare and difficult to distinguish from benign parathyroid tumours. Prediction of malignancy often relies on intraoperative assessment of invasion. Standard histology is also inadequate; especially in the absence of local invasion, lymph nodal disease and metastasis. The aim of this project was to systematically review published literature on potential bio-markers used for the diagnosis of parathyroid cancer. METHODS Pubmed, Web of Science and Medline databases were searched. Inclusion criteria included English language papers published after 1985 and reporting on biomarkers in human studies of parathyroid cancer and benign disease. RESULTS 118 relevant papers were appraised; all were observational studies. At least 2 papers studied 8 serum, 4 urine and 27 tissue biomarkers on the diagnosis of parathyroid cancer. Of these, 5 serum and 13 tissue markers have been demonstrated in at least one study to be statistically different in benign and malignant disease. We present a synthesis of data for each biomarker and measures of diagnostic accuracy where possible. CONCLUSIONS Consideration should be given to the use of a panel of biomarkers to review patients with suspected parathyroid cancer. A profile including serum calcium and PTH levels and tissue expression of APC, Parafibromin, PGP9.5, Galectin 3 and Ki67 is proposed. Systematic Review Registration Number - CRD42019127833.
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Affiliation(s)
- Matthew Philip Davies
- Faculty of Medicine, Dentistry and Health, The University of Sheffield, United Kingdom.
| | | | - Fawzia Tahir
- Sheffield Teaching Hospitals NHS Foundation Trust, United Kingdom
| | - Saba P Balasubramanian
- Faculty of Medicine, Dentistry and Health, The University of Sheffield, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, United Kingdom
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Juhlin CC, Erickson LA. Genomics and Epigenomics in Parathyroid Neoplasia: from Bench to Surgical Pathology Practice. Endocr Pathol 2021; 32:17-34. [PMID: 33269427 PMCID: PMC7960610 DOI: 10.1007/s12022-020-09656-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 12/11/2022]
Abstract
The majority of parathyroid disease encountered in routine practice is due to single parathyroid adenoma, of which the majority arise as sporadic tumors. This is usually a straightforward diagnosis in endocrine pathology when in the appropriate clinical setting, although subsets of cases will exhibit atypical histological features that may warrant additional immunohistochemical and genetic analyses to estimate the malignant potential. Parathyroid carcinomas on the other hand, are bona fide malignant tumors characterized by their unequivocal invasion demonstrated through routine histology or metastasis. The ultimate endpoint for any molecular marker discovered through laboratory investigations is to be introduced in clinical routine practice and guide the surgical pathologist in terms of diagnostics and prognostication. For parathyroid tumors, the two main diagnostic challenges include the distinction between parathyroid adenoma and parathyroid carcinoma, as well as the pinpointing of hereditable disease for familial screening purposes. While numerous markers on genetic, epigenetic, and protein levels have been proposed as discriminative in these aspects, this review aims to condense the scientific coverage of these enigmatic topics and to propose a focused surgical pathology approach to the subject.
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Affiliation(s)
- C Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden.
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden.
| | - Lori A Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Pereira CA, Garrido S, Amaral C, Lima O, Cardoso H. Severe symptomatic hyperparathyroidism-Is it carcinoma?-Case report and literature review. Clin Case Rep 2020; 8:1476-1482. [PMID: 32884778 PMCID: PMC7455427 DOI: 10.1002/ccr3.2886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 12/05/2022] Open
Abstract
Parathyroid carcinoma is a rare disease, difficult to diagnose and associated with a poor prognosis. It must be suspected preoperatively, based on clinical and imaging grounds, in order to perform the best surgical option and avoid compromising patient's prognosis.
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Affiliation(s)
- Catarina A. Pereira
- Endocrinology DepartmentCentro Hospitalar e Universitário do PortoPortoPortugal
| | - Susana Garrido
- Endocrinology DepartmentCentro Hospitalar e Universitário do PortoPortoPortugal
| | - Cláudia Amaral
- Endocrinology DepartmentCentro Hospitalar e Universitário do PortoPortoPortugal
| | - Olinda Lima
- Anatomopathology DepartmentCentro Hospitalar e Universitário do PortoPortoPortugal
| | - Helena Cardoso
- Endocrinology DepartmentCentro Hospitalar e Universitário do PortoPortoPortugal
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Rodrigo JP, Hernandez-Prera JC, Randolph GW, Zafereo ME, Hartl DM, Silver CE, Suárez C, Owen RP, Bradford CR, Mäkitie AA, Shaha AR, Bishop JA, Rinaldo A, Ferlito A. Parathyroid cancer: An update. Cancer Treat Rev 2020; 86:102012. [PMID: 32247225 DOI: 10.1016/j.ctrv.2020.102012] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/09/2020] [Accepted: 03/17/2020] [Indexed: 02/07/2023]
Abstract
Parathyroid cancer (PC) is a rare malignant tumor which comprises 0.5-5% of patients with primary hyperparathyroidism (PHPT). Most of these cancers are sporadic, although it may also occur as a feature of various genetic syndromes including hyperparathyroidism-jaw tumor syndrome (HPT-JT) and multiple endocrine neoplasia (MEN) types 1 and 2A. Although PC is characterized by high levels of serum ionized calcium (Ca) and parathyroid hormone (PTH), the challenge to the clinician is to distinguish PC from the far more common entities of parathyroid adenoma (PA) or hyperplasia, as there are no specific clinical, biochemical, or radiological characteristic of PC. Complete surgical resection is the only known curative treatment for PC with the surgical approach during initial surgery strongly influencing the outcome. In order to avoid local recurrence, the lesion must be removed en-bloc with clear margins. PC has high recurrence rates of up to 50% but with favorable long-term survival rates (10-year overall survival of 60-70%) due to its slow-growing nature. Most patients die not from tumor burden directly but from uncontrolled severe hypercalcemia. In this article we have updated the information on PC by reviewing the literature over the past 10 years and summarizing the findings of the largest series published in this period.
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Affiliation(s)
- Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, IUOPA, CIBERONC, Oviedo, Spain.
| | | | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear, Harvard Medical School Boston, MA, USA
| | - Mark E Zafereo
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Dana M Hartl
- Division of Surgical Oncology, Gustave Roussy Cancer Center and Paris-Sud University, Villejuif Cedex, Paris, France
| | - Carl E Silver
- Department of Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Carlos Suárez
- Instituto de Investigación Sanitaria del Principado de Asturias, CIBERONC, Oviedo, Spain
| | - Randall P Owen
- Division of Surgical Oncology, Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA
| | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ashok R Shaha
- Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin A Bishop
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Sungu N, Dogan HT, Kiliçarslan A, Kiliç M, Polat S, Tokaç M, Akbaba S, Parlak Ö, Balci S, Ögüt B, Çakir B. Role of calcium-sensing receptor, Galectin-3, Cyclin D1, and Ki-67 immunohistochemistry to favor in the diagnosis of parathyroid carcinoma. INDIAN J PATHOL MICR 2018; 61:22-26. [PMID: 29567879 DOI: 10.4103/ijpm.ijpm_85_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background As histopathological findings of parathyroid carcinoma are not certain, the diagnosis of tumors with degenerative changes may be difficult. In these cases, immunohistochemical markers are beneficial. We aimed to research the acceptability of calcium-sensing receptor (CaSR), Galactin-3, Cyclin D1, and Ki-67 as helpful markers in parathyroid tumors in cases which are difficult to diagnose. Materials and Methods Those cases who had been diagnosed with atypical parathyroid adenoma and parathyroid carcinoma between 2010 and 2015 were reevaluated. İmmunohistochemical markers were applied to this cases. Results About 21 cases were parathyroid adenoma, 14 were atypical adenoma, and 10 cases were parathyroid carcinoma. According to the immunohistochemical results, global loss of CaSR staining was seen in 50% (5/10) of the patients with carcinoma while there was no loss of staining in those with parathyroid adenoma (P = 0,001). Global loss of CaSR staining was found in only one out of 14 cases with atypical adenoma. The expression of Galactin-3 was found to be positive in 40% (4/10) of carcinoma cases, 71.4% (10/14) of those with atypical adenoma, and 14.3% (3/21) of those with adenoma (P = 0,002). Cyclin D1 expression was determined to be positive in 70% (7/10) of patients with carcinoma, 71.4% (10/14) of atypical adenoma cases, and 23.8% (5/21) of those with adenoma. The Ki-67 proliferation index was seen to be above 5% in 50% (5/10) of carcinoma cases and 35,7% (5/14) of those with atypical adenoma. Conclusion In these studies, it has been emphasized that the global loss of CaSR staining was used as a negative marker in the diagnosis of carcinoma. In this study, we have also confirmed that the global loss of CaSR staining is a useful marker to determine potential increased malignancy.
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Affiliation(s)
- Nuran Sungu
- Department of Pathology, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Hayriye Tatli Dogan
- Department of Pathology, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Aydan Kiliçarslan
- Department of Pathology, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Mehmet Kiliç
- Department of General Surgery, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Sefika Polat
- Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Mehmet Tokaç
- Department of General Surgery, Yeni Yüzyıl University, Gaziosmanpaşa Hospital, İstanbul, Turkey
| | - Soner Akbaba
- Department of General Surgery, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Ömer Parlak
- Department of General Surgery, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Serdar Balci
- Department of Pathology, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Betül Ögüt
- Department of Pathology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Bekir Çakir
- Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazit University, Faculty of Medicine, Ataturk Education and Research Hospital, Ankara, Turkey
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Tsoli M, Angelousi A, Rontogianni D, Stratakis C, Kaltsas G. Atypical manifestation of parathyroid carcinoma with late-onset distant metastases. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170106. [PMID: 29118988 PMCID: PMC5670324 DOI: 10.1530/edm-17-0106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/10/2017] [Indexed: 12/13/2022] Open
Abstract
Parathyroid carcinoma is an extremely rare endocrine malignancy that accounts for less than 1% of cases of primary hyperparathyroidism. We report a 44-year-old woman who presented with fatigue and diffuse bone pain. Laboratory findings revealed highly elevated serum calcium and parathyroid hormone (PTH) levels and a 4.5 × 3 × 2.5 cm cystic lesion in the lower pole of the right thyroid lobe that was shown histologically to be a parathyroid carcinoma. Ten years later, the patient developed brain and pulmonary metastases and recurrence of PTH-related hypercalcemia. Treatment of hypercalcemia along with localized radiotherapy and various chemotherapy regimens failed to induce a biochemical or radiological response. In conclusion, parathyroid carcinoma is a rare neoplasia that may develop metastases even after prolonged follow-up, for which there is no evidence-based treatment besides surgery. Different chemotherapeutic schemes did not prove to be of any benefit in our case highlighting the need for registering such patients to better understand tumor biology and develop specific treatment.
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Affiliation(s)
- Marina Tsoli
- Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Angelousi
- Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Constantine Stratakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Gregory Kaltsas
- Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
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Ryhänen EM, Leijon H, Metso S, Eloranta E, Korsoff P, Ahtiainen P, Kekäläinen P, Tamminen M, Ristamäki R, Knutar O, Löyttyniemi E, Niskanen L, Väisänen M, Heiskanen I, Välimäki MJ, Laakso M, Haglund C, Arola J, Schalin-Jäntti C. A nationwide study on parathyroid carcinoma. Acta Oncol 2017; 56:991-1003. [PMID: 28362521 DOI: 10.1080/0284186x.2017.1306103] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Parathyroid carcinoma (PC) is rare and diagnostically challenging. Reported outcomes are rather poor and the incidence might be increasing. MATERIAL AND METHODS We performed a nationwide study on all cases (n= 32) diagnosed in 2000-2011 in Finland, and compared clinical and histopathological characteristics and outcome to atypical parathyroid (APA; n= 28) and parathyroid adenomas (PA; n= 72). The incidence in years 1955-1999 was compared to that in 2000-2013. RESULTS Preoperatively, calcium and parathyroid hormone concentrations were higher in PC compared to APA and PA (1.76, 1.56 and 1.44 mmol/l, p < .001; and 989, 355 and 160 μmol/l, p < .001, respectively). Calcium was ≤1.77 mmol/l for all PAs. Hospitalization (44% vs. 22% and 3%, respectively, p = .01), renal (50% vs. 48% vs. 22%, respectively, p = .01) and bone (47% vs. 15% vs. 38%, respectively p = .002) manifestations were more common. PC and APA tumors were larger than PA (p < .001). Histopathological characteristics of PC compared to PA are increased mitotic activity (p= .001), chief cells (p = .003), diffuse growth pattern (p < .001), higher Ki67 (p< .001) and negative parafibromin (p < .001). One PC (1/18) and one APA (1/16) patient had a CDC73 mutation. After 6.7 (2-13.9) years of follow-up, 9.4% of PC had residual, 21% recurrent disease and 12.5% died of disease. Overall mortality did not differ between subgroups (p = .094). Recurrent PC was characterized by vascular invasion, lymph node metastases, high mitotic activity, necrosis and negative parafibromin. Incidence increased from 1.42 (range 0.52-2.14) to 7.14 (range 3.42-10.38)/10.000.000/years; (p < .001). CONCLUSIONS PC associates with severe primary hyperparathyroidism and must be suspected if calcium ≥1.77 mmol/l. The prevalence of CDC73 germline mutations in PC and APA in Finland is 6%. PC has distinct histopathological characteristics and its incidence has increased over the past decades.
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Affiliation(s)
- Eeva M. Ryhänen
- The Division of Endocrinology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Helena Leijon
- Department of Pathology, Huslab and University of Helsinki, Helsinki, Finland
| | - Saara Metso
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Eija Eloranta
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Pirkko Korsoff
- Department of Internal Medicine, Satakunta Central Hospital, Pori, Finland
| | - Petteri Ahtiainen
- Department of Internal Medicine, Central Finland Central Hospital, Jyväskylä, Finland
| | - Päivi Kekäläinen
- Department of Internal Medicine, North Carelia Central Hospital, Joensuu, Finland
| | - Marjo Tamminen
- Department of Internal Medicine, Kymenlaakso Central Hospital, Kotka, Finland
| | - Raija Ristamäki
- Department of Oncology, Turku University Hospital, Turku, Finland
| | - Otto Knutar
- Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland
| | | | - Leo Niskanen
- The Division of Endocrinology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Väisänen
- Department of Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Heiskanen
- Department of Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Matti J. Välimäki
- The Division of Endocrinology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Laakso
- Institute of Clinical Medicine, Internal Medicine, University of Eastern Finland and Kuopio University Hospital, Finland
| | - Caj Haglund
- Department of Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Research Programs Unit, Translational Cancer Biology, University of Helsinki, Helsinki, Finland
| | - Johanna Arola
- Department of Pathology, Huslab and University of Helsinki, Helsinki, Finland
| | - Camilla Schalin-Jäntti
- The Division of Endocrinology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Korpi-Hyövälti E, Cranston T, Ryhänen E, Arola J, Aittomäki K, Sane T, Thakker RV, Schalin-Jäntti C. CDC73 intragenic deletion in familial primary hyperparathyroidism associated with parathyroid carcinoma. J Clin Endocrinol Metab 2014; 99:3044-8. [PMID: 24823466 PMCID: PMC4207936 DOI: 10.1210/jc.2014-1481] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT CDC73 mutations frequently underlie the hyperparathyroidism-jaw tumor syndrome, familial isolated hyperparathyroidism (FIHP), and parathyroid carcinoma. It has also been suggested that CDC73 deletion analysis should be performed in those patients without CDC73 mutations. OBJECTIVE To investigate for CDC73 deletion in a family with FIHP previously reported not to have CDC73 mutations. PATIENTS AND METHODS Eleven members (six affected with primary hyperparathyroidism and five unaffected) were ascertained from the family, and multiplex ligation-dependent probe amplification was performed to detect CDC73 deletion using leukocyte DNA. RESULTS A previously unreported deletion of CDC73 involving exons 1-10 was detected in five affected members and two unaffected members who were 26 and 39 years of age. Two affected members had parathyroid carcinomas at the ages of 18 and 32 years, and they had Ki-67 proliferation indices of 5 and 14.5% and did not express parafibromin, encoded by CDC73. Primary hyperparathyroidism in the other affected members was due to adenomas and atypical adenomas, and none had jaw tumors. Two affected members had thoracic aortic aneurysms, which in one member occurred with parathyroid carcinoma and renal cysts. CONCLUSION A previously unreported intragenic deletion of exons 1 to 10 of CDC73 was detected in a three-generation family with FIHP, due to adenomas, atypical adenomas, and parathyroid carcinomas. In addition, two affected males had thoracic aortic aneurysms, which may represent another associated clinical feature of this disorder.
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Affiliation(s)
- Eeva Korpi-Hyövälti
- Department of Internal Medicine, Seinäjoki Central Hospital (E.K.-H.), 60320 Seinäjoki, Finland; Oxford Medical Genetics Laboratory, Churchill Hospital (T.C.), Division of Endocrinology, Department of Medicine (E.R., T.S., C.S-J.), Department of Pathology (J.A.), and Department of Medical Genetics (K.A), Helsinki University Central Hospital, FI-00290 Helsinki, Finland; and Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford (R.V.T.), Oxford OX1 2JD, United Kingdom
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14
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Simonds WF. Parathyroid cancer and the CDC73 tumor suppressor gene. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2014. [DOI: 10.2217/ije.14.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Parathyroid carcinoma (PC) is a rare endocrine neoplasm, usually causing severe primary hyperparathyroidism, that frequently causes death from unmanageable hypercalcemia. PC is frequently associated with somatic inactivating mutations of the CDC73 gene (previously called HRPT2), a gene discovered in association with the familial hyperparathyroidism-jaw tumor syndrome. DNA analysis for CDC73 mutation should be performed on all patients with seemingly sporadic PC since some 25% will carry a germline mutation. It is often difficult to make a firm diagnosis of PC by histopathology alone. That diagnosis often depends on the presence of local tissue invasion or distant metastases. If PC is suspected, en bloc resection at initial surgery is recommended. Medical therapy with cinacalcet, bisphosphonates or denosumab may temporarily ameliorate the hypercalcemia of inoperable PC.
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Truran PP, Johnson SJ, Bliss RD, Lennard TWJ, Aspinall SR. Parafibromin, Galectin-3, PGP9.5, Ki67, and Cyclin D1: Using an Immunohistochemical Panel to Aid in the Diagnosis of Parathyroid Cancer. World J Surg 2014; 38:2845-54. [DOI: 10.1007/s00268-014-2700-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Campennì A, Ruggeri RM, Sindoni A, Giovinazzo S, Calbo E, Ieni A, Calbo L, Tuccari G, Baldari S, Benvenga S. Parathyroid carcinoma presenting as normocalcemic hyperparathyroidism. J Bone Miner Metab 2012; 30:367-72. [PMID: 22246083 DOI: 10.1007/s00774-011-0344-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 12/11/2011] [Indexed: 02/04/2023]
Abstract
Parathyroid carcinoma (PC) is a rare malignancy, with an indolent but progressive course. Long-term survival is largely dependent on the extent of the primary surgical resection. Hence, pre- or intraoperative suspicion of malignancy is of great importance. We describe the case of a 62-year-old woman with a 2-year history of asthenia and mental depression. Her past medical history was significant for osteoporosis. A diagnosis of primary normocalcemic hyperparathyroidism was established and the patient underwent surgery. PC was suspected intraoperatively because of the size and appearance of the parathyroid mass (a grayish, lobulated 3.5 cm mass). Thus, aggressive surgery (en bloc resection) was performed, along with bilateral neck exploration. Pathological examination of the specimens confirmed the suspicion of PC, demonstrating vascular invasion and extracapsular infiltration into adjacent soft tissue. Immunohistochemical staining revealed an elevated Ki-67 score (8.43%; cut-off value 5%). The mean area of silver-stained nucleolar organizer regions (AgNOR) was high (4.972 μm(2)), indicating an elevated proliferation rate. Serum calcium and parathyroid hormone levels normalized postoperatively, and the patient's 5-year outcome was good. The present case provides evidence that parathyroid malignancy cannot be excluded a priori based on normocalcemic hyperparathyroidism, emphasizing the variability in clinical presentation. Moreover, Ki-67 expression and AgNOR analysis confirmed their additional value in complementing the histological evaluation of a parathyroid malignant mass.
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Affiliation(s)
- Alfredo Campennì
- Unità di Medicina Nucleare, Dipartimento di Scienze Radiologiche, Padiglione E, piano terra, Policlinico Universitario G. Martino, University of Messina, v. Consolare Valeria, 98125, Messina, Italy.
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18
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Kim HK, Oh YL, Kim SH, Lee DY, Kang HC, Lee JI, Jang HW, Hur KY, Kim JH, Min YK, Chung JH, Kim SW. Parafibromin immunohistochemical staining to differentiate parathyroid carcinoma from parathyroid adenoma. Head Neck 2011; 34:201-6. [PMID: 21717519 DOI: 10.1002/hed.21716] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2010] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Parafibromin is a protein encoded by the HRPT2 oncosuppressor gene, and the expression is reported to be decreased or absent in parathyroid carcinomas. METHODS A total of 26 tumor specimens from 18 patients with adenoma and 8 patients with carcinoma were immune-stained with an antibody against parafibromin. RESULTS Parafibromin immunostaining showed strong positivity in 17 of 18 adenomas. Negative staining was noted in 3 of 8 carcinomas, and weak positivity was found in 3 of 8 carcinomas. The remaining 2 cases of carcinoma showed strong positivity. The loss of parafibromin expression (negative or weak positivity) demonstrated 94.4% specificity in the diagnosis of parathyroid carcinomas. Relapses or distant metastases of carcinoma occurred only in cases in which there was a loss of parafibromin immunostaining. CONCLUSIONS Loss of parafibromin immunostating showed promising results in the differential diagnosis of parathyroid carcinoma from adenoma and may also serve as a prognostic marker.
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Affiliation(s)
- Hee Kyung Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Abstract
Parathyroid cancer is an uncommon malignancy and rare cause of primary hyperparathyroidism (HPT) with a high morbidity and patient death in advanced cases usually resulting from intractable hypercalcemia. Inactivation of the HRPT2/CDC73 gene, encoding the putative tumor-suppressor protein parafibromin and discovered in the context of the hyperparathyroidism-jaw tumor (HPT-JT) syndrome, is a common, somatic event in most parathyroid cancers. Approximately 25% of patients with apparently sporadic parathyroid cancer carry germline HRPT2/CDC73 mutation. Germline DNA analysis for HRPT2/CDC73 mutation is recommended in all patients with parathyroid cancer because of the potential benefit for first-degree relatives, who should nevertheless undergo serum calcium screening. The histopathologic diagnosis of parathyroid cancer is nonspecific unless vascular, lymphatic, capsular, or soft tissue invasion is seen, or metastases are clinically evident. Immunohistochemical analysis of parathyroid tumors for loss of parafibromin expression offers promise as a diagnostic tool. En bloc tumor resection offers the highest chance of cure in patients with suspected parathyroid carcinoma. No adjuvant chemotherapy regimen has yet proven effective, and the role of local adjuvant radiotherapy is being evaluated. Metastatic disease can be palliated with surgical debulking. Medical therapy with the calcimimetic cinacalcet and bisphosphonates can ameliorate hypercalcemia in patients with inoperable disease.
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Affiliation(s)
- John M Sharretts
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892–1752, USA
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20
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Adam MA, Untch BR, Olson JA. Parathyroid carcinoma: current understanding and new insights into gene expression and intraoperative parathyroid hormone kinetics. Oncologist 2010; 15:61-72. [PMID: 20051478 DOI: 10.1634/theoncologist.2009-0185] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Parathyroid carcinoma is an indolent but ultimately life-threatening malignancy. Due to the lack of definitive diagnostic markers and overlapping clinical features of benign primary hyperparathyroidism (PHPT), this disease is often misdiagnosed as parathyroid adenoma. Therefore, a high index of suspicion preoperatively and early intraoperative recognition with en bloc surgical resection are crucial for favorable outcome. Owing to the rarity of the disease, little is known about the molecular pathogenesis of parathyroid carcinoma. Here, we review the literature to present current understanding of the disease and provide new information on gene expression and use of intraoperative parathyroid hormone (PTH) monitoring in the surgical management of this rare malignancy. Specifically, using microarray transcriptome analysis of an unequivocal case of parathyroid carcinoma and a biopsy from the same patient's normal parathyroid gland, we identify APP, CDH1, KCNJ16, and UCHL1 as differentially expressed genes in parathyroid carcinoma. Further, using case records from four cases of unequivocal parathyroid carcinoma, we compared intraoperative PTH kinetics of these patients to 475 patients with benign PHPT, and show that intraoperative PTH monitoring is accurate in predicting postoperative normocalcemia in initial en bloc operations for parathyroid carcinoma.
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21
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Juhlin CC, Höög A. Parafibromin as a diagnostic instrument for parathyroid carcinoma-lone ranger or part of the posse? Int J Endocrinol 2010; 2010:324964. [PMID: 21197463 PMCID: PMC3005812 DOI: 10.1155/2010/324964] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 11/08/2010] [Indexed: 11/17/2022] Open
Abstract
The diagnosis of parathyroid carcinoma requires an invasive growth pattern or metastases detected at histopathological examination; unfortunately, not all carcinomas exhibit visible malignant properties at the initial assessment. Therefore, immunohistochemical markers have been sought for the recognition of parathyroid malignancy. In 2003, the Hyperparathyroidism 2 (HRPT2) gene was found mutated in the majority of sporadic parathyroid carcinomas investigated, and studies regarding the protein product parafibromin proposed loss of nuclear parafibromin as a highly sensitive marker for the detection of parathyroid carcinoma. Recent studies have not fully reproduced these findings, as subsets of carcinomas display positive parafibromin immunoreactivity, and fractions of adenomas demonstrate absent expression. Overall, parafibromin is a marker of value to the endocrine pathologist, but it cannot be recommended as a sole indicator of parathyroid carcinoma. Additional markers such as protein gene product 9.5 (PGP9.5) and adenomatous polyposis coli (APC) could complement parafibromin when assessing malignant potential of parathyroid tumours.
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Affiliation(s)
- C. Christofer Juhlin
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital Solna, 17176 Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Karolinska University Hospital Solna, 17176 Stockholm, Sweden
- *C. Christofer Juhlin:
| | - Anders Höög
- Department of Oncology-Pathology, Karolinska Institute, Karolinska University Hospital Solna, 17176 Stockholm, Sweden
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Affiliation(s)
- Wen T Shen
- Department of Surgery, Section of Endocrine Surgery, Mt. Zion Medical Center, University Of California San Francisco, Hellman Bldg. Room C-349, Campus Box 1674, San Francisco, CA 94115, USA.
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Cetani F, Pardi E, Ambrogini E, Banti C, Viacava P, Borsari S, Bilezikian J, Pinchera A, Marcocci C. Hyperparathyroidism 2 gene (HRPT2, CDC73) and parafibromin studies in two patients with primary hyperparathyroidism and uncertain pathological assessment. J Endocrinol Invest 2008; 31:900-4. [PMID: 19092296 PMCID: PMC5319599 DOI: 10.1007/bf03346439] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
HRPT2 and parafibromin studies improved the diagnostic accuracy in two patients with primary hyperparathyroidism (PHPT) referred to us after surgery, in whom the clinical data were at variance with the pathological diagnosis of adenoma and carcinoma, respectively. Patients were referred to us after parathyroidectomy. Patient #1 had had a 1.5-cm tumor easily removed with a histological diagnosis of parathyroid carcinoma and normocalcemia for 2 years. Re-examination of the histology showed no cardinal signs of parathyroid cancer. Patient #2, with severe PHPT, had had the removal of a 3.5-cm tumor described histologically as adenoma. Ten years later PHPT recurred and persisted despite removal of two mildly enlarged parathyroid glands that were histologically normal. Re-review of the initial histology showed a trabecular pattern, fibrous bands, and atypical mitoses, suggesting an atypical adenoma. Because of the suspicion that case #1 could be an atypical adenoma and case #2 a carcinoma further molecular studies were performed. No HRPT2 and parafibromin abnormalities were identified in patient #1, strongly indicating a benign lesion. In patient #2, an HRPT2 germline mutation was found (E115X in exon 4) and associated with no parafibromin staining. These data, together with the clinical features, supported the suspicion of a parathyroid carcinoma that was confirmed by histological examination of further slides of the tumor, showing capsular and vascular invasion. A lung 1.5-cm nodule detected by computed tomography was excised. Histology showed a metastasis of parathyroid carcinoma. HRPT2 gene studies improved the diagnostic accuracy in 2 parathyroid tumors that are of uncertain type.
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Affiliation(s)
- F. Cetani
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - E. Pardi
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - E. Ambrogini
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - C. Banti
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - P. Viacava
- Department of Oncology (Section of Pathology), University of Pisa, Pisa, Italy
| | - S. Borsari
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - J.P. Bilezikian
- Department of Medicine and Pharmacology, Columbia University College of Physicians & Surgeons, New York, NY 10032, USA
| | - A. Pinchera
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - C. Marcocci
- Department of Endocrinology, University of Pisa, Pisa, Italy
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Cetani F, Pardi E, Banti C, Borsari S, Ambrogini E, Vignali E, Cianferotti L, Viccica G, Pinchera A, Marcocci C. HRPT2 gene analysis and the diagnosis of parathyroid carcinoma. Expert Rev Endocrinol Metab 2008; 3:377-389. [PMID: 30754207 DOI: 10.1586/17446651.3.3.377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Parathyroid carcinoma is an uncommon cause of primary hyperparathyroidism (PHPT) and is usually associated with more severe clinical manifestations than its much more common benign counterpart, the parathyroid adenomas. The histopathological distinction between benign and malignant parathyroid tumors is difficult. Currently, pathological diagnosis of parathyroid carcinoma is restricted to lesions showing unequivocal growth, as evidenced by perineural invasion, full-thickness capsular invasion with growth into adjacent tissues, or metastasis. Major advances in the molecular pathogenesis of parathyroid carcinoma have been made by the cloning of the HRPT2 gene, which encodes parafibromin, a 531-amino acid putative tumor-suppressor protein. Germline mutations of HRPT2 confer susceptibility to the hyperparathyroidism-jaw tumor syndrome (HPT-JT), an autosomal dominant syndrome with high but incomplete penetrance. Somatic inactivating mutations of the HRPT2 gene have been reported in the majority of apparently sporadic parathyroid carcinomas but, unexpectedly, germline HRPT2 mutation have been found in up to 30% of these patients. Several studies have been performed to evaluate whether parafibromin immunostaining might have some diagnostic utility. Loss of parafibromin immunoreactivity has been found in the majority of parathyroid carcinomas, in 50% of equivocal carcinomas and, very rarely, in benign adenomas. On the other hand, with the exception of HPT-JT-related tumors, loss of parafibromin associated with HRPT2 mutations strongly predicts parathyroid malignancy. In clinical practice, parafibromin immunostaining and HRPT2 gene analysis could be particularly useful in the subset of parathyroid tumors with equivocal histology.
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Affiliation(s)
- Filomena Cetani
- a Department of Endocrinology and Metabolism, Via Paradisa, 2, 56124 Pisa, Italy.
| | - Elena Pardi
- b Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Chiara Banti
- c Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Simona Borsari
- d Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Elena Ambrogini
- e Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Edda Vignali
- f Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | | | - Giuseppe Viccica
- h Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Aldo Pinchera
- i Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Claudio Marcocci
- j Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
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Foppiani L, Del Monte P, Sartini G, Arlandini A, Quilici P, Bandelloni R, Marugo A, Bernasconi D. Intrathyroidal Parathyroid Carcinoma as Cause of Hypercalcemia and Pitfall of Localization Techniques: Clinical and Biologic Features. Endocr Pract 2007; 13:176-81. [PMID: 17490933 DOI: 10.4158/ep.13.2.176] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe an unusual case of intrathyroidal parathyroid carcinoma (PC), which was retrospectively diagnosed in a woman who underwent surgical treatment of a recurrent nodular goiter. METHODS We report the clinical and biologic features of an intrathyroidal PC, discuss the challenges with distinguishing PC from parathyroid adenoma, and review the related literature. RESULTS A 67-year-old woman sought medical attention for dysphagia attributable to the recurrence of a normal functioning multinodular goiter. Thyroid ultrasonography disclosed a 3-cm solid inferior nodule. Because she refused surgical treatment and a trial of levothyroxine was unsuccessful, periodic follow-up examinations were scheduled. At 1-year follow-up, hypercalcemia (12.1 to 12.6 mg/dL) and low phosphorus levels (2.0 to 2.3 mg/dL) were found, and parathyroid hormone (PTH) levels were profoundly increased (481 to 721 pg/mL). Neck ultrasonography showed a large hypoechogenic solid nodule, not clearly cleaved from the right thyroid lobe, which was possibly compatible with an enlarged parathyroid gland; however, a sestamibi scan was negative. During total thyroidectomy, intraoperative frozen sections of the intrathyroid nodule were compatible with nodular goiter with cellular pleomorphism. Final histologic examination showed cellular nests with nuclear pleomorphism and invasive behavior into the thyroid tissue and likely into the vessels, in conjunction with immunohistochemical negativity for thyroglobulin and strong positivity for PTH. These findings were highly suggestive of and supported the diagnosis of PC. Postoperatively, calcium levels normalized, and PTH values declined considerably but remained slightly increased. Vitamin D supplementation helped normalize the PTH levels. The patient has undergone follow-up for 5 years and has shown no morphologic or biochemical signs of tumor recurrence. CONCLUSION PC is a rare entity but should be suspected in patients with hypercalcemia, substantially increased PTH levels, and a neck mass. In such patients, techniques such as sestamibi scanning may fail to localize the neoplasm. Surgical treatment remains the preferred technique for an optimal outcome of the disease. Nevertheless, lifelong follow-up is necessary.
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Affiliation(s)
- Luca Foppiani
- Division of Endocrinology, Galliera Hospital, Genova, Italy
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Gill AJ, Clarkson A, Gimm O, Keil J, Dralle H, Howell VM, Marsh DJ. Loss of nuclear expression of parafibromin distinguishes parathyroid carcinomas and hyperparathyroidism-jaw tumor (HPT-JT) syndrome-related adenomas from sporadic parathyroid adenomas and hyperplasias. Am J Surg Pathol 2006; 30:1140-9. [PMID: 16931959 DOI: 10.1097/01.pas.0000209827.39477.4f] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Parathyroid carcinoma is notoriously difficult to diagnose with confidence in borderline cases. Commonly there is a long lag time between diagnosis and clinical evidence of malignant behavior even in histopathologically straightforward lesions. There is therefore a need for a novel adjunctive marker to assist in the diagnosis of carcinoma. Parafibromin is the protein encoded by the putative tumor suppressor gene HRPT2. Mutations predicted to inactivate parafibromin were first detected in the germline of patients with hyperparathyroidism-jaw tumor (HPT-JT) syndrome. Subsequently, somatic mutations have been identified in the majority of sporadic carcinomas. We performed immunohistochemistry for parafibromin on 115 parathyroid tissues comprising 4 HPT-JT-related tumors (3 adenomas and 1 carcinoma), 11 sporadic parathyroid carcinomas, 79 sporadic adenomas, 3 multiple endocrine neoplasia 2A-related adenomas, 2 sporadic primary hyperplasias, 2 multiple endocrine neoplasia (MEN)-1-related hyperplasias, 6 secondary hyperplasias, 4 tertiary hyperplasias, and 4 normal parathyroid glands. There was complete absence of nuclear staining in 3 of 4 (75%) HPT-JT-related tumors and 8 of 11 (73%) sporadic parathyroid carcinomas and focal weak staining in 1 of 4 HPT-JT tumors and 2 of 11 sporadic parathyroid carcinomas. Only 1 parathyroid carcinoma exhibited diffuse strong nuclear expression of parafibromin. In contrast, 98 of 100 non-HPT-JT-related benign parathyroids showed diffuse strong nuclear positivity and 2 of 100 showed weak positive staining. We conclude that, in the correct clinical and pathologic context, complete absence of nuclear staining for parafibromin is diagnostic of parathyroid carcinoma or an HPT-JT-related tumor.
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Affiliation(s)
- Anthony J Gill
- Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, Australia.
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Kelly TG, Shattuck TM, Reyes-Mugica M, Stewart AF, Simonds WF, Udelsman R, Arnold A, Carpenter TO. Surveillance for early detection of aggressive parathyroid disease: carcinoma and atypical adenoma in familial isolated hyperparathyroidism associated with a germline HRPT2 mutation. J Bone Miner Res 2006; 21:1666-71. [PMID: 16995822 DOI: 10.1359/jbmr.060702] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
UNLABELLED Familial hyperparathyroid syndromes involving mutations of HRPT2 (also CDC73), a tumor suppressor, are important to identify because the relatively high incidence of parathyroid malignancy associated with such mutations warrants a specific surveillance strategy. However, there is a dearth of reports describing experience with surveillance and early detection informed by genetic insight into this disorder. INTRODUCTION Familial isolated hyperparathyroidism (FIHP) is a rare cause of parathyroid (PT) tumors without other neoplasms or endocrinopathies. Germline mutations in CASR, MEN1, and rarely, HRPT2 have been identified in kindreds with FIHP. HRPT2 mutations may be enriched in FIHP families with PT carcinoma, underscoring the importance of identifying causative mutations. MATERIALS AND METHODS A 13-year-old boy, whose father had died of PT carcinoma, developed primary hyperparathyroidism. A left superior PT mass was identified by ultrasonography and removed surgically. Aggressive histological features of the boy's tumor included fibrous trabeculae, mitoses, and microscopic capsular infiltration. Two years later, under close biochemical surveillance, primary hyperparathyroidism recurred 5 months after documentation of normocalcemia and normal parathyroid status. Ultrasound and MRI identified a newly enlarged right superior PT gland but indicated no recurrent disease in the left neck. Histologic features typical of a benign adenoma were evident after surgical extirpation of the gland. RESULTS Leukocyte DNA analysis revealed a frameshift mutation in exon 2 of HRPT2. The initial tumor manifested the expected germline HRPT2 mutation, plus a distinct somatic frameshift mutation, consistent with the Knudson "two hit" concept of biallelic inactivation of a classic tumor suppressor gene. Genetic screening of the patient's 7 asymptomatic and previously normocalcemic siblings revealed three with the same germline HRPT2 mutation. One of the siblings newly identified as mutation-positive was noted to be hypercalcemic at the time of the genetic screening. He was found to have a PT adenoma with aggressive features. Two of the five children of another mutation-positive sibling also carry the same HRPT2 mutation. CONCLUSIONS Despite the reported rarity of HRPT2 mutations in FIHP, a personal or family history of PT carcinoma in FIHP mandates serious consideration of germline HRPT2 mutation status. This information can be used in diagnostic and management considerations, leading to early detection and removal of potentially malignant parathyroid tumors.
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Affiliation(s)
- Thomas G Kelly
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut 06520-8064, USA
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Vieira JGH, Ohe MN, Hauache OM, Oliveira UMD, Delana JM, Gonçalves A, Lazaretti-Castro M. Carcinoma de paratiróide. ACTA ACUST UNITED AC 2005; 49:811-5. [PMID: 16444365 DOI: 10.1590/s0004-27302005000500023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Carcinoma de paratiróide é uma condição rara, correspondendo na maior parte das casuísticas a menos de 1% dos casos de hiperparatiroidismo primário (HPP). No entanto, pela sua gravidade, e com o prognóstico dependente do diagnóstico precoce e de uma conduta agressiva, é fundamental que a suspeita clínica seja feita pré-operatoriamente. As características clínicas são compatíveis com um caso de HPP grave, sintomático, com tumor cervical >1,5cm, podendo ser palpável. A definição anátomo-patológica pode ser difícil em muitos casos. Nossa casuística (1983-2004) compreende 7 casos, todos sintomáticos, com síndrome hipercalcêmica e doença óssea presente na maioria. Em 6/7 o tumor era palpável, e todos apresentavam quadro bioquímico compatível. Três pacientes faleceram em quadro de hipercalcemia refratária. Dados recentes apontam para uma mutação no gene HRPT2 como base molecular para o desenvolvimento destes tumores. A conduta é cirúrgica e deve incluir hemitiroidectomia e exploração cervical ampliada, procurando focos metastáticos. O pós-operatório é compatível com a gravidade da alteração metabólica pré-existente, sendo comum a tendência a hipocalcemia. O prognóstico de longo prazo depende do diagnóstico precoce, do sucesso cirúrgico e do controle da hipercalcemia. Novas possibilidades terapêuticas, na forma de bisfosfonatos e drogas calcimiméticas, bem como a possibilidade de diagnóstico genético, tendem a melhorar o prognóstico desta grave condição.
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Affiliation(s)
- José Gilberto H Vieira
- Serviço de Doenças Osteo-Metabólicas, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo, SP.
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Johnson SJ, Sheffield EA, McNicol AM. Best practice no 183. Examination of parathyroid gland specimens. J Clin Pathol 2005; 58:338-42. [PMID: 15790694 PMCID: PMC1770637 DOI: 10.1136/jcp.2002.002550] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The pathological examination of parathyroid glands is an essential component of the evaluation of hyperparathyroidism. Traditionally, this has involved intraoperative frozen sections during bilateral surgical exploration of the neck, to confirm removal of parathyroid tissue. With recent developments in imaging, some diseased glands can be localised preoperatively, enabling removal by minimally invasive, targetted surgery, with or without additional non-histological intraoperative procedures to confirm the removal of all hyperfunctioning parathyroid tissue. This article reviews these developments and describes the ideal approach to reporting parathyroid specimens.
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Affiliation(s)
- S J Johnson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK.
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Abstract
Parathyroid carcinoma is a rare tumor that is responsible for <1% of cases of hyperparathyroidism in most parts of the world. An increased incidence of this tumor has been reported in patients with the hyperparathyroidism-jaw tumor (HPT-JT) syndrome, but the etiology of most other cases is unknown. Parathyroid carcinomas tend to occur a decade earlier than adenomas, and the sex ratio approaches unity in contrast to the female preponderance of adenomas. Most patients with carcinomas present with marked hypercalcemia and are more likely to have associated bone and renal disease than those with adenomas. Although fibrosis and mitotic activity are common in carcinomas, these features are not specific for malignancy. The diagnosis of carcinoma should be restricted to those tumors that show invasion of blood vessels, perineural spaces, soft tissues, thyroid gland, or other adjacent structures or to tumors with documented metastases. Mutations of the HRPT2 gene (1q21-q32), which are responsible for the HPT-JT syndrome, have been implicated in the development of a high proportion of parathyroid carcinomas. A subset of patients with mutation-positive carcinomas have germline mutations of the HRPT2 gene. This finding suggests that some patients with apparent sporadic parathyroid carcinomas may have the HPT-JT syndrome or a variant of this syndrome. Because of the high frequency of local recurrence following incomplete excision, an en bloc resection is the preferred surgical approach for treatment of parathyroid carcinomas.
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Affiliation(s)
- Ronald A DeLellis
- Department of Pathology, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island 02903, USA.
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Tan MH, Morrison C, Wang P, Yang X, Haven CJ, Zhang C, Zhao P, Tretiakova MS, Korpi-Hyovalti E, Burgess JR, Soo KC, Cheah WK, Cao B, Resau J, Morreau H, Teh BT. Loss of Parafibromin Immunoreactivity Is a Distinguishing Feature of Parathyroid Carcinoma. Clin Cancer Res 2004; 10:6629-37. [PMID: 15475453 DOI: 10.1158/1078-0432.ccr-04-0493] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE A reliable method for diagnosing parathyroid carcinoma has remained elusive over the years, resulting in its under-recognition and suboptimal therapy. Obtaining an accurate diagnosis has become an even more pressing matter with recent evidence that germline HRPT2 gene mutations are found in patients with apparently sporadic parathyroid carcinoma. There is a high prevalence of HRPT2 gene mutations and biallelic inactivation in parathyroid carcinoma. We hypothesize that loss of parafibromin, the protein product of the HRPT2 gene, would distinguish carcinoma from benign tissue. EXPERIMENTAL DESIGN We generated a novel antiparafibromin monoclonal antibody and performed immunostaining on 52 definite carcinoma specimens, 6 equivocal carcinoma specimens, 88 benign specimens, and 9 hyperparathyroidism-jaw tumor (HPT-JT) syndrome-related adenomas from patients with primary hyperparathyroidism from nine worldwide centers and one national database. RESULTS We report that the loss of parafibromin nuclear immunoreactivity has 96% sensitivity [95% confidence interval (CI), 85-99%] and 99% specificity (95% CI, 92-100%) in diagnosing definite carcinoma. Inter-observer agreement for evaluation of parafibromin loss was excellent, with unweighted kappa of 0.89 (95% CI, 0.79-0.98). Two equivocal carcinomas misclassified as adenomas were highlighted by parafibromin immunostaining. One of these tumors has since recurred, satisfying criteria for a definite carcinoma. Similarly, eight of nine HPT-JT syndrome-related adenomas showed absent nuclear immunoreactivity. CONCLUSIONS Parafibromin is a promising molecular marker for diagnosing parathyroid carcinoma. The similar loss of parafibromin immunoreactivity in HPT-JT syndrome-related adenomas suggests that this is a pivotal step in parathyroid tumorigenesis.
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Affiliation(s)
- Min-Han Tan
- Laboratory of Cancer Genetics, Van Andel Research Institute, Grand Rapids, Michigan 49503, USA
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Cetani F, Pardi E, Viacava P, Pollina GD, Fanelli G, Picone A, Borsari S, Gazzerro E, Miccoli P, Berti P, Pinchera A, Marcocci C. A reappraisal of the Rb1 gene abnormalities in the diagnosis of parathyroid cancer. Clin Endocrinol (Oxf) 2004; 60:99-106. [PMID: 14678295 DOI: 10.1111/j.1365-2265.2004.01954.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Some histological features may suggest the malignant nature of a parathyroid tumour. However, the diagnosis of parathyroid cancer can only be definitively established in the presence of local invasion or metastases. DESIGN We further investigated the role of the retinoblastoma gene (Rb1) and the breast cancer susceptibility gene (BRCA2) in the differential diagnosis between benign and malignant parathyroid tumours by evaluating loss of heterozygosity (LOH) at these loci and Rb protein (pRb) immunohistochemistry. PATIENTS AND MEASUREMENTS Fifty-three parathyroid adenomas from patients with sporadic primary hyperparathyroidism (PHPT) and 10 parathyroid cancer specimens were studied. Microsatellite polymorphisms at the Rb1 and BRCA2 loci were polymerase chain reaction (PCR) amplified from each patient's paired tumour and leucocyte DNA samples, using oligonucleotide primers flanking the repeat sequence. Immunohistochemical staining of pRb was carried out using a monoclonal antibody. RESULTS All but one of the 53 tumour-leucocyte pairs was informative for at least one of the three polymorphic markers of the Rb1 gene. Fifteen adenomas (28.8%) showed LOH. Regarding the BRCA2 gene, 46 tumour-leucocyte pairs were informative and LOH was present in eight (17.4%). All six carcinomas had LOH for at least one marker at the Rb1 locus. LOH for the BRCA2 microsatellite was found in three of the five informative primary tumour samples. Immunohistochemical analysis revealed that all adenomas were positive and the number of pRb-positive cells varied significantly among different samples. The mean percentage of stained cells was 15.7%. Eleven of the 30 (36.7%) adenomas showed sparse positive staining, 13 (43.3%) intermediate staining and six (20%) extensive staining. All parathyroid cancers were entirely negative for pRb immunostaining. CONCLUSIONS Inactivation of the Rb1 gene is a common event in parathyroid tumorigenesis. Retention of heterozygosity seems to exclude parathyroid malignancy, which is suggested by the combined finding of LOH and lack of protein expression.
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Affiliation(s)
- Filomena Cetani
- Dipartimenti di Endocrinologia e Metabolismo, Ortopedia e Traumatologia, Medicina del Lavoro, Università di Pisa, Pisa, Italy
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Howell VM, Haven CJ, Kahnoski K, Khoo SK, Petillo D, Chen J, Fleuren GJ, Robinson BG, Delbridge LW, Philips J, Nelson AE, Krause U, Hammje K, Dralle H, Hoang-Vu C, Gimm O, Marsh DJ, Morreau H, Teh BT. HRPT2 mutations are associated with malignancy in sporadic parathyroid tumours. J Med Genet 2003; 40:657-63. [PMID: 12960210 PMCID: PMC1735580 DOI: 10.1136/jmg.40.9.657] [Citation(s) in RCA: 222] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Hyperparathyroidism is a common endocrinopathy characterised by the formation of parathyroid tumours. In this study, we determine the role of the recently identified gene, HRPT2, in parathyroid tumorigenesis. METHODS Mutation analysis of HRPT2 was undertaken in 60 parathyroid tumours: five HPT-JT, three FIHP, three MEN 1, one MEN 2A, 25 sporadic adenomas, 17 hyperplastic glands, two lithium associated tumours, and four sporadic carcinomas. Loss of heterozygosity at 1q24-32 was performed on a subset of these tumours. RESULTS HRPT2 somatic mutations were detected in four of four sporadic parathyroid carcinoma samples, and germline mutations were found in five of five HPT-JT parathyroid tumours (two families) and two parathyroid tumours from one FIHP family. One HPT-JT tumour with germline mutation also harboured a somatic mutation. In total, seven novel and one previously reported mutation were identified. "Two-hits" (double mutations or one mutation and loss of heterozygosity at 1q24-32) affecting HRPT2 were found in two sporadic carcinomas, two HPT-JT-related and two FIHP related tumours. CONCLUSIONS The results in this study support the role of HRPT2 as a tumour suppressor gene in sporadic parathyroid carcinoma, and provide further evidence for HRPT2 as the causative gene in HPT-JT, and a subset of FIHP. In light of the strong association between mutations of HRPT2 and sporadic parathyroid carcinoma demonstrated in this study, it is hypothesised that HRPT2 mutation is an early event that may lead to parathyroid malignancy and suggest intragenic mutation of HRPT2 as a marker of malignant potential in both familial and sporadic parathyroid tumours.
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Affiliation(s)
- V M Howell
- Laboratory of Cancer Genetics, Van Andel Research Institute, 333 Bostwick NE, Grand Rapids, Michigan 49503, USA
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Shattuck TM, Kim TS, Costa J, Yandell DW, Imanishi Y, Palanisamy N, Gaz RD, Shoback D, Clark OH, Monchik JM, Wierman ME, Hollenberg A, Tojo K, Chaganti RSK, Arnold A. Mutational analyses of RB and BRCA2 as candidate tumour suppressor genes in parathyroid carcinoma. Clin Endocrinol (Oxf) 2003; 59:180-9. [PMID: 12864795 DOI: 10.1046/j.1365-2265.2003.01814.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Strong evidence indicates that at least one key tumour suppressor gene important for the development of malignant parathyroid tumours is located on chromosome 13, but the critical target gene remains unknown. Importantly, the region of acquired DNA loss includes two established tumour suppressor genes, the retinoblastoma gene, RB (RB1) and BRCA2. Resolution of whether RB or BRCA2 is the critical 13q tumour suppressor gene in parathyroid cancer requires analysis of these genes' sequences for intragenic inactivating mutations. Therefore, RB and BRCA2 were analysed in a group of parathyroid carcinomas in which mutations of these genes should be most readily detectable. PATIENTS AND DESIGN Six parathyroid carcinomas from four patients which showed loss of heterozygosity (LOH) at the RB locus and/or 13q loss by comparative genomic hybridazation (CGH) were selected from a CGH/LOH-screened panel of 16 carcinoma specimens from 10 patients. These tumours were examined for mutations by direct sequencing of the complete 27-exon coding region, intron-exon boundaries and promoter of RB. The 26 coding exons and intron-exon boundaries of BRCA2 were also directly sequenced in seven parathyroid carcinomas with loss in the BRCA2 region. RESULTS No microdeletions, insertions, or point mutations were detected in either RB or BRCA2 in any of the carcinomas. CONCLUSION The absence of tumour-specific somatic mutations in RB and BRCA2 suggests that they are unlikely to act as classic tumour suppressor genes in the pathogenesis of parathyroid carcinomas. While decreased expression of these genes might contribute to parathyroid carcinomatosis in a secondary fashion and 13q loss warrants further study as a diagnostic marker for parathyroid carcinoma, the putative 13q tumour suppressor awaits identification.
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Affiliation(s)
- Trisha M Shattuck
- Center for Molecular Medicine and Division of Endocrinology & Metabolism, University of Connecticut School of Medicine, Farmington, 06030-3101, USA
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Kameyama K, DeLellis RA, Lloyd RV, Kakudo K, Takami HE. Parathyroid carcinomas: can clinical outcomes for parathyroid carcinomas be determined by histologic evaluation alone? Endocr Pathol 2002; 13:135-9. [PMID: 12165662 DOI: 10.1385/ep:13:2:135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Fifth Annual Meeting of the Japan Endocrine Pathology Society was held in September 2001. A highlight of the meeting was the participation of Japanese and American endocrine pathologists in a conference to consider the topic "The Determination of Clinical Outcomes for Parathyroid Carcinomas by Histological Evaluation of Invasive Growth." The discussion was centered around three cases of parathyroid carcinomas selected by the coordinator, Dr. Kameyama, and discussed by Drs. Ronald DeLellis, Ricardo Lloyd, and Kennichi Kakudo. In this article, we summarize their diagnoses and comments.
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Affiliation(s)
- Kaori Kameyama
- Division of Diagnostic Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
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Affiliation(s)
- E Shane
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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40
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Kytölä S, Farnebo F, Obara T, Isola J, Grimelius L, Farnebo LO, Sandelin K, Larsson C. Patterns of chromosomal imbalances in parathyroid carcinomas. THE AMERICAN JOURNAL OF PATHOLOGY 2000; 157:579-86. [PMID: 10934160 PMCID: PMC1850113 DOI: 10.1016/s0002-9440(10)64568-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this study we have characterized chromosomal imbalances in a panel of 29 parathyroid carcinomas using comparative genomic hybridization (CGH). The most frequently detected imbalances were losses of 1p and 13q that were seen in >40% of the cases. The commonly occurring regions of loss were assigned to 1p21-p22 (41%), 13q14-q31 (41%), 9p21-pter (28%), 6q22-q24 (24%), and 4q24 (21%), whereas gains preferentially involved 19p (45%), Xc-q13 (28%), 9q33-qter (24%), 1q31-q32 (21%) and 16p (21%). The distribution of CGH alterations supports the idea of a progression of genetic events in the development of parathyroid carcinoma, where gains of Xq and 1q would represent relatively early events that are followed by loss of 13q, 9p, and 1p, and by gain of 19p. A sex-dependent distribution was also evident for two of the common alterations with preferential gain of 1q in female cases and of Xq in male cases. When the CGH profiles for the 29 carcinomas were compared with our previously published results for sporadic parathyroid adenomas, highly significant differences were revealed. Loss of 1p, 4q, and 13q as well as gains of 1q, 9q, 16p, 19p and Xq were significantly more common in the carcinomas than in the adenomas. In contrast, loss of the 11q13 region, which is the most common CGH abnormality in sporadic adenomas, was not detected in any of the carcinomas. Taken together, the findings identify several candidate locations for tumor suppressor genes and oncogenes that are potentially involved in parathyroid carcinogenesis.
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Affiliation(s)
- Soili Kytölä
- Endocrine Genetics Unit, and the Departments of Surgery‡
| | - Filip Farnebo
- Endocrine Genetics Unit, and the Departments of Surgery‡
| | - Takao Obara
- Tokyo Women’s Medical University, Tokyo, Japan; and The Laboratory of Cancer Genetics,¶
| | | | - Lars Grimelius
- Karolinska Hospital, Stockholm, Sweden; the Department of Endocrine Surgery,†
| | - Lars-Ove Farnebo
- Institute of Medical Technology, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Kerstin Sandelin
- Institute of Medical Technology, University of Tampere and Tampere University Hospital, Tampere, Finland
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Kameyama K, Takami H, Sanders D, Giordano TJ. Surgical pathology of hyperparathyroidism. Biomed Pharmacother 2000; 54 Suppl 1:42s-45s. [PMID: 10914989 DOI: 10.1016/s0753-3322(00)80009-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- K Kameyama
- Division of Diagnostic Pathology, Keio Universitv Hospital, Tokyo, Japan
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Kameyama K, Takami H, Umemura S, Osamura YR, Wada N, Sugino K, Mimura T, Ito K. PCNA and Ki-67 as prognostic markers in human parathyroid carcinomas. Ann Surg Oncol 2000; 7:301-4. [PMID: 10819371 DOI: 10.1007/s10434-000-0301-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is widely accepted that histological diagnosis of parathyroid tumors is established with great difficulty. Carcinomas cannot be reliably separated from adenomas by histology alone. In this study, immunohistochemical staining for proliferating cell nuclear antigen (PCNA) and Ki-67 was determined in 10 cases of parathyroid carcinomas, labeling indices (LIs) were calculated, and the results were correlated with the clinical outcomes. METHODS Ten cases of formalin-fixed, paraffin-embedded tissue with surgically resected parathyroid carcinoma were used. Immunohistochemical staining for PCNA and Ki-67 was performed and the LIs were calculated. We also examined whether LI could become a useful marker for parathyroid carcinomas. RESULTS Although nine patients with minimally invasive growth without recurrence of the tumor showed a low LI for both markers, one patient with a widely invasive neoplasm, and who died, had a high LI. CONCLUSIONS These results suggested that the LI of PCNA and Ki-67, in addition to the histological appearance, may be markers of the biological behavior of parathyroid carcinomas. However, this study was on a small scale, so it may be valuable to repeat these studies in a larger group of patients with better defined histological criteria.
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Affiliation(s)
- K Kameyama
- Division of Diagnostic Pathology, Keio University Hospital, Tokyo, Japan
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Farnebo F, Svensson A, Thompson NW, Bäckdahl M, Grimelius L, Larsson C, Farnebo LO, Sandelin K. Expression of matrix metalloproteinase gelatinase A messenger ribonucleic acid in parathyroid carcinomas. Surgery 1999; 126:1183-7. [PMID: 10598205 DOI: 10.1067/msy.2099.101420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The incidence of parathyroid cancer in patients with hyperparathyroidism is less than 1%. However, these few cases cause diagnostic problems in the absence of clear-cut invasion of adjacent organs or metastasis. New markers are needed to increase diagnostic accuracy. METHODS Thirty-one parathyroid tumors from patients with primary hyperparathyroidism were collected worldwide. Eighteen tumors were classified as unequivocal cancers, whereas 13 tumors were considered equivocal because of a lack of infiltrative growth or evidence of recurrence. Paraffin sections were hybridized with a 35S-labeled riboprobe complementary to gelatinase A mRNA, dipped in photographic emulsion, developed, counterstained, and then evaluated by light- and dark-field microscopy. RESULTS Fourteen of the 18 unequivocal parathyroid cancers expressed gelatinase A, as compared with the equivocal tumors, of which only 4 of 13 showed expression. The strongest hybridization signal was seen in stromal cells at the tumor border, most likely fibroblasts and macrophages. No expression was detected in tumor cells. CONCLUSIONS Invasive growth of many tumors is facilitated by proteolytic enzymes, such as gelatinase A. The presence of gelatinase A mRNA in parathyroid tumors strengthens the suspicion of malignancy but cannot be used as a definitive marker of malignancy.
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Affiliation(s)
- F Farnebo
- Department of Molecular Medicine, Karolinska Hospital, Stockholm, Sweden
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