Incidental parathyroid adenomas with normocalcemia discovered during thyroid operations: report of three cases

Intratracheal parathyroid gland: an unexpected diagnosis

Ectopic or supernumerary parathyroid tissue has been generally described in the literature in cases found during workup for parathyroid adenoma. We present two unique cases of intratracheal parathyroid gland, a rare occurrence that has not yet been described in the literature. In both cases, the masses were found incidentally and showed no clinical or laboratory evidence of hyperparathyroidism. In both cases, surveillance was chosen as the method of treatment. We present this case series to increase awareness of this potential diagnosis.

Sudden Odynophagia and Globus-A Unique Presentation of a Nonsecreting Parathyroid Adenoma: A Case Report and Literature Review

Parathyroid adenomas are most commonly diagnosed when symptoms consistent with primary hyperparathyroidism arise. However, certain parathyroid glands may enlarge without such symptoms. Described here is a case in which a patient presented with acute signs of unilateral cervical point tenderness, dysphagia, and odynophagia. Calcium and parathyroid hormone levels tested within normal range. Imaging revealed an enlarged right-sided mass, with compression of the trachea-esophageal groove and potentially the right recurrent laryngeal nerve. Surgical excision was performed, and final pathology revealed an infarcted parathyroid adenoma. Clinical symptoms promptly resolved thereafter. Current NIH criteria for parathyroidectomy include various symptoms of hyperparathyroidism but do not include the above findings. Nonsecreting parathyroid adenomas rarely cause laryngeal symptoms, as this has only been documented once before.

Addison disease and normocalcemic primary hyperparathyroidism in a dog with multiple endocrine neoplasia

A 12-year old dog with a 9-year history of primary adrenal insufficiency was referred to the service for hyporexia, muscle weakness, polyuria and polydipsia. Ultrasound examination showed an unresectable mass in the left adrenal gland, with local vascular invasion, which prompted the euthanasia of the animal. Additionally, necropsy revealed a nodular lesion in the right adrenal gland and enlargement of one of the four parathyroid glands. Parathyroid hormone levels were elevated, but ionized and total calcium levels were normal. Histopathology supported the diagnosis of parathyroid chief cell adenoma and bilateral pheochromocytoma. Immunohistochemical staining was positive for synaptophysin, and negative for Melan-A and calretinin, which confirmed the diagnosis of pheochromocytoma. This case highlights an unusual presentation of multiple endocrine neoplasias within the context of primary adrenal insufficiency and normocalcemic primary hyperparathyroidism.

Ectopic Parathyroid Incidentaloma on Tc99m SestaMIBI Myocardial Perfusion Imaging

Parathyroid incidentalomas are generally discovered during thyroid surgery.^[1] In the present case, the ectopic parathyroid adenoma was discovered as an incidentaloma in a clinical setting, during the course of clinical evaluation of atypical chest pain by gastroenterology and cardiology.

Challenging neck mass: non-functional giant parathyroid adenoma

A 46-year-old man was referred to our ear, nose and throat department after the accidental discovery of a large retrotracheal mass. In order to obtain the diagnosis and to plan treatment he underwent a full battery of tests (CT, MRI, blood tests, hormonal assays, ultrasounds, thyroid scintigraphy, urine tests and fine-needle aspiration of the mass), but none of these was able to define the true nature of such cervical mass. Only after surgical excision and histological evaluation, it was diagnosed as an exceptional case of giant non-functional parathyroid adenoma.

Parathyroid incidentaloma

Incidentalomas are lesions which are asymptomatic and detected incidently during imaging or surgery. Parathyroid incidentalomas are a rare entity. Enlargement of gland without hyperfunction may be an early stage of disease. Symptomatology is usually non-specific or related to renal and skeletal system. Total serum calcium estimation may be used as a screening modality. Sestamibi scan is a more accurate imaging technique than USG. FNAB - PTH measurement is the most reliable minimally invasive nonsurgical test for parathyroid tissue verification. Incidently discovered enlarged parathyroid gland may be removed to avoid a re-do surgery.

Parathyroid incidentalomas detected during thyroid ultrasonography and effect of chronic thyroiditis on false positive parathyroid lesions

We aimed to determine the prevalence of parathyroid incidentalomas in patients referred for thyroid ultrasonography (US) and investigate the role of chronic thyroiditis on false positive lesions. Patients suspected to have parathyroid lesions during thyroid US were recorded prospectively between August 2009 and January 2010. Patients referred for parathyroid US and patients with known high serum calcium or parathyroid hormone (PTH) levels were excluded. Suspected parathyroid lesions were defined as hypoechoic, homogeneous, solid lesions with regular margins located outside the thyroid lobe, most commonly inferior to the thyroid gland. Thyroid US was performed in 6,528 patients. There were 78 patients (1.19 %) (73 female and 5 male) with suspected parathyroid lesion. The diagnosis of a true parathyroid adenoma was confirmed in 6 (7.69 %) patients. In patients with true adenoma, mean serum calcium, phosphorus, and PTH levels were 10.57 ± 0.48 mg/dl, 3.03 ± 0.52 mg/dl, and 182.91 ± 46.62 pg/ml, respectively. Among 72 patients with false positive parathyroid lesion, antithyroid peroxidase antibody was positive in 50 (69.4 %), antithyroglobulin antibody was positive in 46 (63.9 %), and one of these antibodies were positive in 59 (81.9 %) patients. Also, 46 (63.9 %) of these patients had thyroid dysfunctions (43 hypothyroidism and 3 hyperthyroidism) and 59 (81.9 %) had chronic thyroiditis ultrasonographically. Parathyroid incidentaloma was detected in 0.09 % of patients referred for thyroid US. The presence of clinically or ultrasonographically chronic thyroiditis might cause inadvertent interpretation of a hypoechoic lesion as a parathyroid pathology during thyroid US.

Incidental Parathyroid Disease during Thyroid Surgery: Should We Remove Them?

Aim. Despite an incidence of parathyroid "incidentalomas" of 0.2%-4.5%, only approximately 135 cases have been reported in the literature. We present eight patients in whom an incidental abnormal parathyroid gland was found during routine thyroid surgery. We have reviewed the literature and postulate whether these glands could represent further evidence of a preclinical stage of primary hyperparathyroidism. Methods. A retrospective analysis of all 236 thyroid operations performed by a single surgeon was performed to identify patients in whom abnormal parathyroid tissue was removed at surgery. Results. 8/236 patients (3.39%) had a single macroscopically abnormal parathyroid gland removed and sent for analysis. Seven patients were found to have histological evidence of a parathyroid adenoma or hyperplasia. None of the patients had abnormal serum calcium detected preoperatively. Postoperatively, four patients had normal calcium, three had temporary hypocalcaemia and one refused followup. No patients had recurrent laryngeal nerve impairment. Conclusions. Despite the risk of removing a histologically normal gland, we believe that when parathyroid "incidentalomas" are found during surgery they should be excised and sent for histological analysis. We have found this to be a safe procedure with minimal morbidity to the patient. As the natural history of primary hyperparathyroidism is better understood, these glands found in normocalcaemic patients may in fact represent the early or preclinical phase of the disease. By removing them at the original operation, the patient is saved redo neck surgery with its high complication rate as or when clinically apparent primary hyperparthryoidism develops in the future.

EG. Associação de doença tireoideana ao adenoma de paratireóide

OBJETIVO: avaliar a prevalência de doença incidental de tireóide em tratamento cirúrgico por HPP. MÉTODO: De janeiro de 1998 a dezembro de 2004, 20 pacientes com evidência clínica e laboratorial de HPP foram submetidos à paratiroidectomia. A população de pacientes incluía 15 mulheres e cinco homens, com idade variando de 44 a 83 anos. Os dados utilizados para o diagnóstico de doença tireoidiana: clínico, laboratorial, ultra-sonografia com Doppler, exame citopatológico da punção aspirativa por agulha fina (PAAF) e exame durante a exploração intra-operatória. Todos os pacientes eram portadores de adenoma de paratireóide, sendo dois duplos. RESULTADOS: Ao exame clínico foi detectado alteração à palpação da tireóide em sete pacientes, com cinco indicações cirúrgicas; a avaliação laboratorial mostrou alteração da função tireoidiana em três pacientes; a ultra-sonografia mostrou doença nodular em 15 pacientes, mas não determinou indicação cirúrgica; a PAAF de nódulo tireoidiano foi indicada em nove pacientes, com três pacientes de carcinoma papilífero; a exploração intra-operatória não adicionou achado ao exame ultra-sonográfico. CONCLUSÃO: A associação patológica entre doenças da tireóide e da paratireóide é freqüente. A ultra-sonografia é o método mais sensível de detecção, porém, o exame clínico e a PAAF são os que revelaram impacto na indicação cirúrgica sobre a glândula tireóide no momento da paratireoidectomia.

Incidentalomas of The Parathyroid Gland: Multiple Presentations, Variable Function, and Review of the Literature

OBJECTIVE

To present a series of cases of parathyroid incidentalomas and review the related medical literature.

METHODS

The medical records of all patients of one surgeon who underwent unplanned removal of enlarged parathyroid glands found either during a surgical procedure performed for indications other than hyperparathyroidism or by ultrasonography of the thyroid gland between September 1989 and December 2003 were reviewed retrospectively. Clinical and laboratory data-- especially serum calcium and parathyroid hormone (PTH) levels--as well as information on postoperative parathyroid function are reported.

RESULTS

Among 421 patients (355 who underwent thyroidectomy and 66 who underwent transhiatal esophagectomy), 5 cases of parathyroid incidentalomas (1.2%) were identified. These incidental parathyroid adenomas were found during thyroidectomy for thyroid cancer in two patients, during esophagectomy for esophageal cancer in one patient (the first such reported case), and during ultrasonography of the neck for evaluation of thyroid nodules in two patients. Of the five patients, three had a normal and one had a slightly increased serum calcium concentration preoperatively; the serum calcium level was not determined preoperatively in the other patient. In one patient in whom intraoperative PTH level was determined both before and after resection of a large parathyroid adenoma, the initially high PTH value (180 pg/mL) declined to the normal range (48.2 pg/mL). In another patient, bone densitometry 9 months postoperatively showed an 8% increase in T-score for the lumbar spine and a 3.9% increase in T-score at the femoral neck, in comparison with bone density tests done 3 months preoperatively. No patient had persistent or recurrent hyperparathyroidism or hypoparathyroidism postoperatively or during subsequent follow-up.

CONCLUSION

Incidental identification of enlarged parathyroid glands during a neck surgical procedure is not common but does occur. Intraoperative and postoperative measurements of serum calcium and PTH along with postoperative bone density testing can help determine whether such parathyroid incidentalomas are functional. These enlarged parathyroid glands should be removed.

Development of a parathyroid database in Melbourne and review of the last 50 cases

BACKGROUND

Minimally invasive parathyroidectomy (MIP) is only possible if preoperative localization studies accurately identify the abnormal parathyroid tissue. The aim of the present paper was to evaluate the accuracy of these studies in our geographical region and the consequences on MIP.

METHODS

A Filemaker Pro database was designed and a retrospective analysis was carried out on the last 50 parathyroidectomies.

RESULTS

There were a total of 49 patients who underwent parathyroidectomy; with one patient having two operations. Forty-nine preoperative ultrasound localization studies were performed. Ultrasound sensitivity of correct localization of abnormal parathyroids was 41% with a false positive rate of 25%. Twenty-two sestamibi scans identified 14 abnormal parathyroids. Sestamibi scanning had a sensitivity of 32% for correct localization and a false positive rate of 32%. There were 16 different radiologists or nuclear medicine physicians involved with the nuclear medicine scans, and 22 different radiologists involved in the preoperative ultrasound scans. Forty-seven patients were cured of hyperparathyroidism after a primary operation, with a total of 48 patients in all being cured following re-exploration. One patient was lost to follow up. The success of primary exploration was therefore 96% and following re-exploration this increased to 98%.

CONCLUSION

We found preoperative localization studies to have low sensitivities and high false positive rates. To move successfully towards MIP, we need to identify a radiologist with a special interest in localization studies to achieve greater accuracy.