Water-clear cell parathyroid adenoma in a patient with acute pancreatitis

Double water-clear cell parathyroid adenoma: a case report and literature review

Water-clear cell parathyroid adenoma is an uncommon cause of primary hyperparathyroidism. Herein, we report an interesting case of a 56-year-old man who presented with weight loss, bone pain, fatigue, and a palpable right neck mass. Laboratory tests indicated hypercalcemia, elevated parathyroid hormone (PTH) levels, and normal thyroid function. Further examinations detected osteoporosis and kidney stones. The ultrasound of neck revealed bilateral extrathyroidal tumors, which were sestamibi-avid. The patient underwent resection of the large right inferior and left inferior parathyroid tumors. Histopathology revealed a double water-clear cell parathyroid adenoma. His serum calcium and PTH levels normalized after surgery. The literature review identified 37 cases of water-clear cell parathyroid adenoma between 1985 and 2021. The median age at diagnosis was 56 years. Classic complications were common, including nephrolithiasis in nine and skeletal presentations in 10 patients. Before surgery, the median calcium and PTH levels were 12.0 mg/dL and 290 pg/mL, respectively. Overall, 89% were localized on ultrasonography, and 60% were positive on scintigraphy. Four patients had double adenomas. The median maximum diameter was 3.8 cm, and the median weight of the resected adenoma was 5.27 g. In summary, water-clear cell parathyroid adenoma has certain unique features. These include larger tumor size, relatively indolent biochemical profile, high prevalence of complications and nonspecific symptoms, an isoechoic appearance on ultrasonography, and reduced scintigraphic sensitivity.

Triple water clear cell parathyroid adenomas: a rare cause of primary hyperparathyroidism

A man in his 70s was referred to the endocrine surgery department after incidental finding of hypercalcaemia during preoperative work-up for abdominal aortic aneurysm repair. The patient reported severe fatigue and malaise with no previous history of nephrolithiasis or osteoporosis. After biochemical confirmation of primary hyperparathyroidism, localisation studies suggested multiple gland disease. Intraoperatively, three enlarged parathyroid adenomas were found and excised. Histopathological and immunohistochemical examination revealed triple water clear cell (WCC) parathyroid adenomas. Adenomas being entirely composed of WCCs are rare. In addition, triple adenomas are so rare that their existence is disputed by some authors. The present paper reports on an extremely rare case of a patient suffering from triple parathyroid adenomas composed entirely of WCCs. To our knowledge, this is the first such reported case in the English language literature.

Water clear cell ectopic non-iatrogenic giant parathyroid adenoma in sternohyoid muscle with thyroid nodule and asymptomatic hypercalcemia due to primary hyperparathyroidism: Case report and literature review

Background

Ectopic parathyroid gland is not uncommon, and is associated with primary hyperparathyroidism. Giant parathyroid adenoma (PA) and concurrent presence of enlarged thyroid nodule increases the probability of ectopic location. The combination of a giant PA that is ectopic (within the strap muscle) in the neck is very rare, especially in cases with no previous surgery. The rare histopathological findings of the current case, water clear cell parathyroid adenoma (WCCPA), could explain the patient's presentation, since it has low endocrine function.

Case presentation

A 56-year-old Qatari female on routine visit to primary health care physician for hypertension, was incidentally discovered to be hypercalcemic and was referred to the emergency department of our institution. Neck ultrasound showed a thyroid nodule on the left side, but ^99mTc-sestamibi scintigraphy identified a left PA. FNAC of the thyroid nodule showed that it was a colloid nodule. She underwent left hemithyroidectomy and excision of left PA. Intraoperatively, the PA was giant and in the sternohyoid muscle. Intraoperative monitoring of intact PTH (IOiPTH) confirmed successful excision.

Discussion

Ectopic giant parathyroid adenoma is rare especially with the intramuscular location in sternohyoid muscle in the neck without previous neck surgeries. The presence of thyroid nodule could be a precipitating factor for migration of the PA. Preoperative assessment with the radiological image is crucial for diagnosis but sometimes fail to localized the PA.

Conclusion

Giant asymptomatic PA with long standing low function before hyperfunctioning should raise the suspicion of WCCPA. If diagnosis is confirmed, metastasis from a clear cell renal cell carcinoma should be ruled out.

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We report a unique rare case of non-iatrogenic ectopic giant water clear cell parathyroid adenoma (WCCPA)

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A parathyroid adenoma >3.5 gm, asymptomatic and with low function before hyperfunctioning, should raise suspicion of WCCPA.

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History, examination, ultrasound, sesta-MIBI scintigraphy and immunohistochemical studies are important for diagnosis.

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High preoperative parathyroid hormone and calcium need monitoring in post-operative period to avoid hypocalcemia.

Institutional characterisation of water clear cell parathyroid adenoma: a rare entity often unrecognised by TC-99m-sestamibi scintigraphy

Parathyroid lesions exhibiting a water clear cell morphology are exceedingly rare manifestations in primary hyperparathyroidism (PHPT), and the phenomenon has been reported both for uniglandular (water clear cell adenoma; WCCA) and multiglandular disease (water clear cell hyperplasia; WCCH). In all, only 24 previous descriptions of WCCA exist in the literature. Herein, we present seven cases with water clear cell morphology (6 WCCAs and 1 case of WCCH) in an institutional series of approximately 4000 parathyroid lesions spanning 29 years in a tertiary centre setting. Major histological attributes and clinical parameters associated with this morphological subtype were reviewed, and a literature search was conducted. WCCA and WCHH exhibited an institutional prevalence of 0.15% and 0.025%, respectively. All cases displayed histological hallmarks of water clear cell morphology, with cells exhibiting abundant cytoplasm filled with vacuoles. Atypical findings or unequivocal evidence of invasive behaviour were not observed. The gender distribution was 6:1 (F:M), patients were generally symptomatic with mild hypercalcaemia, and the median age at surgery was 53 years (range 38-78). The preoperative localisation was inconclusive in four of seven, and neck exploration of all four glands was undertaken in five cases. The excised WCCAs exhibited an average weight of 1215 mg, markedly higher than conventional adenomas, and all patients were cured of PHPT following parathyroidectomy. Interestingly, previous reports mirror our observations that these lesions often are large, in relation to their sizes biochemically fairly indolent, and indecisively localised using scintigraphy, providing correlations of possible clinical value when pre-operatively assessing these rare lesions.

Parathyroid Pathology

Proliferative pathologic lesions of parathyroid glands encompass a spectrum of entities ranging from benign hyperplastic processes to malignant neoplasia. This review article outlines the pathophysiologic classification of parathyroid disorders and describes histologic, immunohistochemical, and molecular features that can be assessed to render accurate diagnoses.

An unusual cause of hypercalcemic crisis: Water-clear cell double parathyroid adenoma

Objective

To evaluate the clinical characteristics of a patient operated for water-clear cell adenoma and to discuss these in the light of relevant literature.

Material and Methods

PubMed and Google Scholar were searched to identify articles related to water-clear cell adenoma using the following keywords: parathyroid tissue, parathyroid gland, parathyroid cells, parathyroid adenoma, parathyroid hyperplasia, water-clear-cell, and water clear cell. The search included case reports, review articles, and original articles that had been published between January 1990 and November 2014 without any restrictions on language. All articles that contained information on the study population and treatment related data were identified and retrieved. In addition, an evaluation was of a case of a 47-year-old male patient with PHC who was treated at our clinic was conducted.

Results

A total of 19 patients, including our new case, (age range: 18 to 81 years, mean±SD: 57.47±16.31 years) were included in the analysis. Eleven patients were female. Information about adenoma location was available from studies involving 17 patients and they indicated the following distribution of locations: left inferior (n=10), right superior (n=4). When preoperative imaging methods were examined, a false negative result was given by ultrasonography in 28.5% of patients and only 57.1% were positive on scintigraphy. Concomitant thyroid papillary carcinoma was determined in 1 patient. The mean tissue dimensions were 3.47±1.73 cm (range, 0.8-6.8 cm).

Conclusion

Water-clear cell adenoma, which shows similar clinical characteristics to other parathyroid adenomas, is an uncommon cause of hyperparathyroidism.

Water Clear Cell Adenoma of the Parathyroid Gland: A Forgotten Cause of Primary Hyperparathyroidism

Water clear cell adenoma of the parathyroid gland is a rare neoplasm composed of large clear cells with foamy cytoplasm and mild nuclear pleomorphism, compressing the residual nonneoplastic parathyroid tissue. The differential diagnosis includes a variety of neoplasms with clear cell features. In this article, we provide an overview of the entity with a historical perspective, in order to help pathologists in distinguishing it from other neoplasms in their daily practice.

Intrathyroidal Clear Cell Tumor of Parathyroid Origin with Review of Literature

Water-clear cell adenoma (WCCA) of the parathyroid gland is an exceedingly rare neoplasm. To date, 17 cases have been reported in the literature, with only one of them being intrathyroidal. Here we report a case of a 34-year-old woman who presented for evaluation of a goiter and was found to have a thyroid nodule and abnormal thyroid function tests (TFT). Fine needle aspiration biopsy of the nodule revealed thyroid follicular cells without atypia and subsequent Afirma® Gene Expression Classifier (GEC) testing results were suspicious for malignancy. As a result, the patient underwent a right thyroid lobectomy and isthmusectomy. Histological sections revealed an intrathyroidal nodule consistent with a clear cell neoplasm of parathyroid origin. The histologic appearance together with the immune profile was diagnostic of WCCA, with diffuse positivity for GATA3, focal weak positivity for parathyroid hormone, and negativity for PAX8, thyroglobulin, TTF1, synaptophysin, chromogranin, and S100p. Our study focuses on the clinical presentation, current management strategies, and review of the available literature surrounding this rare diagnosis. The ultimate goal is to help endocrinologists and surgeons establish a foundational treatment plan for intrathyroidal clear cell tumor cases.