Coexistent thyroid pathologies and high rate of papillary cancer in patients with primary hyperparathyroidism: controversies about minimal invasive parathyroid surgery

Hypercalcemia in Dual Pathology: Interplay Between Renal Cell Carcinoma and Parathyroid Adenoma

The concomitant occurrence of renal cell carcinoma (RCC) and primary hyperparathyroidism is rare as these conditions are often identified by the presence of hypercalcemia, which might be missed in asymptomatic individuals. We present the case of a 58-year-old asymptomatic male detected to have a left abdominal mass during his routine medical follow-up. He was subsequently diagnosed with RCC. Further history revealed that his calcium levels had been persistently elevated for the past eight years but had never been investigated. Based on elevated parathyroid hormone levels and radiological findings, a diagnosis of primary hyperparathyroidism has also been made. A right inferior parathyroidectomy was performed, and the histopathological examination results showed a right parathyroid adenoma. Intraoperative intact PTH (iPTH) measurements confirmed the complete removal of the abnormal parathyroid gland. The postoperative calcium levels have returned to normal. To the best of our knowledge, this was the first reported case of concurrent primary hyperparathyroidism and RCC in our population. This case illustrates the importance of considering a broad differential when evaluating patients with hypercalcemia.

Risk of Malignant Neoplasm in Patients with Primary Hyperparathyroidism: A Systematic Review and Meta-analysis

This study aimed to evaluate the prevalence and risk of malignant neoplasm in primary hyperparathyroidism (PHPT) patients. Potentially eligible studies were retrieved from PubMed and Embase databases from inception to November 2023 using search strategy consisting of terms for "Primary hyperparathyroidism" and "Malignant neoplasm". Eligible study must report prevalence of malignant neoplasm among patients with PHPT or compare the risk of malignant neoplasm between patients with PHPT and comparators. Point estimates with standard errors were extracted from each study and combined using the generic inverse variance method.A total of 11,926 articles were identified. After two rounds of systematic review, 50 studies were included. The meta-analysis revealed that pooled prevalence rates of overall cancer was 0.19 (95%CI: 0.13-0.25; I2 94%). The two most prevalent types of malignancy among patients with PHPT ware papillary thyroid cancer (pooled prevalence: 0.07; 95%CI: 0.06-0.08; I2 85%) and breast cancer (pooled prevalence: 0.05; 95%CI: 0.03-0.07; I2 87%). Subgroup analysis of studies focusing on patients undergoing parathyroidectomy reported a fourfold higher prevalence of papillary thyroid cancer than the remaining studies (0.08 versus 0.02). The meta-analysis of cohort studies found a significant association between PHPT and overall cancer with the pooled risk ratio of 1.28 (95%CI: 1.23-1.33; I2 66.9%).We found that the pooled prevalence of malignant neoplasm in PHPT was 19%, with papillary thyroid cancer and breast cancer being the most prevalent types. The meta-analysis of cohort studies showed that patient with PHPT carried an approximately 28% increased risk of malignancy.

Predicting coexisting thyroid cancer with primary hyperparathyroidism in an endemic region of multinodular goiter: evaluating the effectiveness of preoperative inflammatory markers

Purpose

The aim is to examine the efficacy of inflammatory indicators to predict thyroid cancer in patients with primary hyperparathyroidism (PHPT) in an endemic region of nodular goiter.

Methods

The prospective database was reviewed to identify patients operated on with the diagnosis of PHPT and thyroid disease between April 2015 and June 2021. Permanent pathologic reports were used as the gold standard for diagnosis. Detailed imaging data with peripheral blood inflammation indices were analyzed to assess their predictive values for concomitant PHPT with thyroid cancer. Postoperative complications and the duration of hospitalization were also reviewed.

Results

Thyroid malignancy accompanying PHPT was found in 13 patients (26.0%) out of 50 who had concurrent surgery. The analysis regarding inflammatory indexes revealed nothing significant between thyroid cancer and preoperative blood biochemistry (P > 0.05). In the concurrent surgery group, recurrent laryngeal nerve injury was observed in 1 patient (2.0%) and the mean hospital stay was longer.

Conclusion

In endemic regions of nodular thyroid disease, thyroid cancer might accompany PHPT. The value of inflammatory indexes to predict thyroid malignancy in PHPT is controversial and should not be employed in the surgical decision-making process.

Analysis of intraoperative laboratory measurements and imaging techniques such as Tc-99 m-MIBI SPECT/CT, 18F-fluorocholine PET/CT and ultrasound in patients operated with prediagnosis of parathyroid adenoma

AIM

The aim of this study is to determine accurately the localization of the adenoma with the imaging methods in the patients, who are planned to be operated on with prediagnosis of parathyroid adenoma.

METHOD

In our study, the files of the patients who were considered to have parathyroid adenoma and underwent operation between 2012 and 2020 with the methods such as Tc99m-MIBI SPECT/CT, 18F-fluorocholine PET/CT, and ultrasound, and biochemical examinations were examined retrospectively.

RESULTS

In this study, 31 (18.2%) male and 139 (81.8%) female adult patients were included. The sensitivities of localization methods were 82.6% for ultrasound and 78.4% for scintigraphy. Adenoma was localised in the right place in 14 of 15 (93.3%) patients with the 18F-fluorocholine PET/CT method. A statistically significant correlation was found between the sensitivity of scintigraphy, the gland weights (p: 0.002), and phosphor values (p: 0.039). A statistically significant improvement was observed in the intact PTH value (p: 0.001) 15 min after the removal of adenoma. A statistically significant improvement was observed in the serum PTH value (p: 0.001), the serum phosphorus value (p: 0.001), and the serum calcium (p: 0.001) in the first 3 months after the operation.

CONCLUSION

Determining localization accurately for the patients enables performing operations with minimally invasive surgery successfully in a shorter time. Also, fewer complications and faster recovery are seen in the patients. It was concluded that studying intraoperative intact PTH and using 18F-fluorocholine PET/CT method for localization give more accurate results for localization and allow having more successful operation outcomes.

Increased thyroid malignancy in patients with primary hyperparathyroidism

BACKGROUND

Multiple studies have reported the increased incidence of thyroid cancer in patients with primary hyperparathyroidism (PHPT). However, the underlying risk factors of concomitant thyroid cancer in patients with PHPT remain unknown. The primary aim of this study was to examine the records of patients with PHPT to identify characteristics that correlated with the presence of coexisting thyroid nodules, and which may have an implication for the prediction of thyroid cancer.

METHODS

Medical records of consecutive patients with PHPT (n = 318) were reviewed from January 2010 to September 2020 in two tertiary medical centers in China. Patient clinicopathological and biological data were collected and analyzed.

RESULTS

Of a total of 318 patients with PHPT, 105 (33.0%) patients had thyroid nodules and 26 (8.2%) patients were concomitant with thyroid cancer. A total of 38 thyroid nodules taken from 26 patients were pathologically assessed to be well-differentiated papillary thyroid carcinoma (PTC), with 81% being papillary thyroid microcarcinoma (PTMC). In 79% (30/38) of these cancers, thyroid nodules were considered suspicious following preoperative ultrasound. Multinomial logistic regression analysis revealed that female gender was associated with increased risk of thyroid nodules (OR = 2.13, 95% CI: 1.13-3.99, P = 0.019), while lower log-transformed parathyroid hormone levels were an independent predictor of thyroid cancer in patients with PHPT (OR = 0.50, 95% CI: 0.26-0.93, P = 0.028).

CONCLUSION

In conclusion, we observed a relatively high prevalence of thyroid cancer in our cohort of Chinese patients with PHPT. Evaluation of thyroid nodules by preoperative ultrasound may be advisable in patients with PHPT, particularly for females and patients with modestly elevated serum parathyroid hormone levels.

Differences in Clinicopathological Characteristics of Papillary Thyroid Carcinoma between Symptomatic and Asymptomatic Patients with Primary Hyperparathyroidism

BACKGROUND

Popularization of cervical ultrasound led to higher detection of papillary thyroid carcinoma (PTC) and primary hyperparathyroidism (PHPT), as well as increasing percentage of asymptomatic PHPT in China. Although the coexistence of PTC and PHPT has been reported, it is unknown whether the clinicopathological features of PTC differ between asymptomatic and symptomatic PHPT patients.

METHODS

We retrospectively reviewed the medical records of 304 PHPT patients treated in our hospital between January 2009 and July 2020, including 217 females and 87 males with the average age of 53.27 ± 13.54 years. Of the 304 patients, 181 were symptomatic PHPT patients and 123 were asymptomatic PHPT patients. We analyzed the laboratory results, postoperative pathology, and the TNM stage of PTC between asymptomatic and symptomatic PHPT patients.

RESULTS

Concurrent thyroid nodules were found in 61.51% of PHPT patients, and the prevalence of PTC in thyroidectomized PHPT patients was 29.89% in our cohort. Lower serum parathyroid hormone (PTH) (p < 0.05) and calcium (p < 0.05) were found in PHPT patients with PTC compared to patients with benign thyroid lesion. Compared with the symptomatic PHPT patients, the asymptomatic PHPT patients showed lower serum calcium (p < 0.05), serum chlorine (p < 0.05), alkaline phosphatase (p < 0.05), PTH (p < 0.05), and bone turnover markers (p < 0.05) but higher prevalence of thyroid nodules (70.73% versus 55.24%, p < 0.05) and PTC (15.44% versus 3.87%, p < 0.05). All the PTC in symptomatic PHPT patients were papillary microcarcinoma limited to the thyroid, while 68.42% and 15.78% of the PTC in asymptomatic PHPT patients showed microscopic extrathyroidal extension and lymph node metastases, respectively. Moreover, 36.84% (7/19) of the PTC patients in asymptomatic group showed multifocality, which was much higher than 14.29% (1/7) in the symptomatic group; however, no statistical significance was found (p=0.24).

CONCLUSIONS

The concomitant PTC in asymptomatic PHPT patients showed a higher rate of microscopic extrathyroidal invasion when compared to symptomatic PHPT patients. So the FNA is essential to the asymptomatic PHPT patients with suspicious thyroid nodules and once the PTC is confirmed, concurrent parathyroidectomy should be performed with thyroidectomy in asymptomatic PHPT patients.

ARE THYROID NODULES AN OBSTACLE TO MINIMAL INVASIVE PARATHYROID SURGERY? A SINGLE-CENTER STUDY FROM AN ENDEMIC GOITER REGION

Context

Minimally invasive parathyroidectomy (MIP) procedure has become a widely accepted alternative to the standard four-gland exploration nowadays.

Objective

The aim of this study was to evaluate patients with primary hyperparathyroidism (PHPT), who had been treated with thyroidectomy and bilateral neck exploration (BNE), rather than MIP alone, due to coexisting thyroid nodules and to determine the benefits of simultaneous thyroidectomy and the possible negative outcomes of not performing this additional procedure.

Design

There were 185 patients who were operated for PHPT at our clinic from January 2014 to November 2016.

Subjects and Methods

50 patients meet inclusion criteria: have thyroidectomy at the same time of parathyroid surgery, have concordant findings of parathyroid adenoma localization at preoperative MIBI-SPECT and the cervical US and have not had malignancy on fine needle aspiration biopsy (FNAB).

Results

The mean age of the patients was 55.3±10.4, and female to male ratio was 7:1. All patients had parathyroidectomy with BNE and thyroidectomy: 11 (22%) patients had micropapillary thyroid cancer (mPTC), 2 (4%) had papillary thyroid cancer (PTC).

Conclusion

The results were inconclusive in clearly demonstrating which patients presenting with coexisted thyroid nodules should undergo thyroidectomy, rather than MIP, and which should be monitored for thyroid nodules after MIP. However, we consider that in cases who are not clearly indicated for thyroidectomy, MIP followed by monitoring of thyroid nodules can be the treatment approach.

Surgical Approach to Primary Hyperparathyroidism in Patients with Concomitant Thyroid Diseases: A Retrospective Single Center Study

BACKGROUND

Primary hyperparathyroidism (PHPT) and thyroid diseases are a frequent concomitant occurrence, but the surgical approach to associated disease is still debated.

METHODS

We retrospectively evaluated a series of PHPT patients focusing on thyroid disease and surgery.

RESULTS

Among 238 PHPT patients undergoing parathyroidectomy (PTX) between 2002 and 2017, 128 were affected also by a benign thyroid disease, namely, goiter in 118 (76 multinodular (MNG) and 42 uninodular (UNG)), autoimmune thyroiditis in 10, and hyperthyroidism in 21. Surgical approach was unilateral neck exploration (UNE) in 59 patients and bilateral neck exploration (BNE) in 69. The PHPT cure rate was 94%. On comparing patients submitted to PTX only and PTX plus thyroidectomy (TX), in the latter MNG and hyperthyroidism were more frequent, and surgical time and length of stay were longer. No difference in surgical complications was found between patients undergoing UNE and BNE.

CONCLUSION

PHPT patients with a concomitant thyroid disease underwent double surgery in almost two-thirds of the cases, mostly by BNE. The main factors driving the decision to perform concomitant PTX and TX were the presence of thyroid nodular disease with the nodule site ipsilateral to the presurgically localized parathyroid adenoma.

Coexistent papillary thyroid carcinoma diagnosed in surgically treated patients for primary versus secondary hyperparathyroidism: same incidence, different characteristics

BACKGROUND

The coexistence of hyperparathyroidism and thyroid cancer presents important diagnostic and management challenges. With minimally invasive parathyroid surgery trending, preoperative thyroid imaging becomes more important as concomitant thyroid and parathyroid lesions are reported. The aim of the study was to evaluate the rate of thyroid cancer in patients operated for either primary (PHPT) or secondary hyperparathyroidism (SHPT).

METHODS

Our retrospective study included PHPT and SHPT patients submitted to parathyroidectomy and, when indicated, concomitant thyroid surgery between 2010 and 2017.

RESULTS

Parathyroidectomy was performed in 217 patients: 140 (64.5%) for PHPT and 77 (35.5%) for SHPT. Concomitant thyroid surgery was performed in 75 patients with PHPT (53.6%), and 19 papillary thyroid carcinomas (PTC) were found, accounting for 13.6% from all cases with PHPT and 25.3% from PHPT cases with concomitant thyroid surgery. Thirty-one of operated SHPT patients (40.3%) also underwent thyroid surgery and 9 PTC cases were diagnosed (11.7% of all SHPT patients and 29% of patients with concomitant thyroid surgery). We found differences between PHPT and SHPT patients (p < 0.001) with respect to age (54.6 ± 13y versus 48.8 ± 12y), female-to-male ratio (8:1 versus ~ 1:1), surgical technique (single gland parathyroidectomy in 82.8% PHPT cases; versus subtotal parathyroidectomy in 85.7% SHPT cases) and presurgical PTH (357.51 ± 38.11 pg/ml versus 1020 ± 161.38 pg/ml). Morphopathological particularities, TNM classification and multifocality incidence of PTC were similar in the two groups. All PTC from patients with SHPT were thyroid microcarcinomas (TMC, i.e. tumors with a diameter smaller than 1 cm), whereas seven out of the 19 cases with PTC and PHPT were larger than 1 cm.

CONCLUSIONS

PTC was frequently and similarly associated with both PHPT and SHPT irrespective of presurgical PTH levels. Thyroid tumors above 1 cm were found only in patients with PHPT. Investigators should focus also on associated thyroid nodular pathology in patients with PHPT.

UNKNOWN AND ALREADY KNOWN THYROID ABNORMALITIES IN PRIMARY HYPERPARATHYROIDISM

OBJECTIVE

Primary hyperparathyroidism (PHPT) and thyroid diseases are highly prevalent in the general population, but the putative link between the 2 conditions remains unclear.

METHODS

A monocentric consecutive series of 434 patients with PHPT was retrospectively evaluated by lab and ultrasonography to look for thyroid abnormalities. Patients were classified in 3 groups: without thyroid abnormalities (group 1, n = 171), with thyroid diseases not previously known (group 2a, n = 69), and thyroid diseases previously known (group 2b, n = 194).

RESULTS

In terms of thyroid disease, no significant difference was found between groups 2a and 2b, except for the significantly larger number of patients with toxic nodular goiter in group 2b. PHPT was more frequently symptomatic in group 2a than in group 2b, despite no differences in serum calcium, creatinine, parathyroid hormone (PTH), or 25-hydroxyvitamin D (25OHD) levels.

CONCLUSION

A total of 60% of PHPT patients had a thyroid disease that was unknown prior to PHPT diagnosis in almost one-third of cases. The newly diagnosed and previously known thyroid diseases were similar, both mostly affecting postmenopausal females.

ABBREVIATIONS

Ab = antibody; aPHPT = asymptomatic PHPT; 25OHD = 25-hydroxyvitamin D; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; Tg = thyroglobulin; TPO = thyroperoxidase; TSH = thyroid-stimulating hormone; US = ultrasound.

Concomitant thyroid disease and primary hyperparathyroidism in patients undergoing parathyroidectomy or thyroidectomy

BACKGROUND

Thyroid abnormalities have been found intraoperatively during parathyroidectomy and have resulted in concomitant thyroidectomy. The identification of concomitant disease is important prior to primary operation in order to minimize reoperations. This study investigates the incidence of concomitant primary hyperparathyroidism (PHPT) and thyroid nodular disease in patients undergoing thyroidectomy or parathyroidectomy.

METHODS

We performed a retrospective review of prospectively gathered data for 621 patients who underwent thyroidectomy, parathyroidectomy, or both at Tulane Medical Center. Information obtained included initial referral, initial thyroid stimulating hormone (TSH), initial parathyroid hormone (PTH), fine needle aspiration (FNA) results, ultrasound results, type of operation performed, final diagnosis, and final pathology.

RESULTS

Among the 400 patients referred primarily for thyroid disease, 13.50% underwent a thyroidectomy and parathyroidectomy (PTX) simultaneously and 10.75% received a final diagnosis of thyroid and concomitant parathyroid disease. Among the 103 patients referred primarily for parathyroid disease, 26.21% underwent a PTX and thyroidectomy and 24.27% received a final diagnosis of both thyroid and parathyroid disease. Patients referred primarily for parathyroid disease were more likely to receive a final diagnosis of both parathyroid and thyroid disease and were more likely to undergo a combined operation.

CONCLUSIONS

Concomitant thyroid and parathyroid disease occur and preoperative analysis is important to avoid increased complications from reoperations.

Management of concomitant hyperparathyroidism and thyroid diseases in the elderly patients: a retrospective cohort study

BACKGROUND

Thyroid disease and hyperparathyroidism are the most common endocrine disorders. The incidence of thyroid disease in patients with hyperparathyroidism ranges in the different series from 17 to 84%, and thyroid cancer occurs with an incidence ranging from 2 to 15%.

AIM

The aim of our study was to analyze the management of elderly patients with concomitant thyroid and parathyroid disease in order to define the best surgical therapeutic strategy and avoid reoperations associated with a higher risk of complications.

METHODS

All consecutive patients (64 patients, age range 60-75 years), undergoing surgery for hyperparathyroidism, from January 2011 to June 2014, were retrospectively evaluated. Enrolled patients were divided into two study groups of patients affected by hyperparathyroidism with or without a concomitant thyroid disease.

RESULTS

Out of 64 patients enrolled in our study (24 men, age range 60-75 years), affected by hyperparathyroidism, 34 had an associated thyroid disease and were treated with total thyroidectomy and parathyroidectomy. The group, who underwent parathyroidectomy associated with thyroidectomy, had no greater complications than the group receiving only parathyroidectomy.

CONCLUSIONS

Thyroid disease must be excluded in patients affected by hyperparathyroidism. It is difficult to determine whether hyperparathyroidism can be considered a risk factor for thyroid disease, but an accurate preoperative study is essential for a surgery able to treat both thyroid and parathyroid disease. In this way, we avoid the elderly patient, with associated morbidity and increased surgical risk, to undergo a reoperation for thyroid disease, burdened with major complications.

Benign and Malignant Thyroid Gland Diseases in the Patients with Primary Hyperparathyroidism

Introduction:

This study aimed to evaluate concurrently detected thyroid pathologies in the patients who underwent surgery for primary hyperparathyroidism (PHPT).

Materials and Methods:

In this study, we retrospectively analyzed the files of the patients who underwent surgery for PHPT between 2012 and 2015. Pre- and post-operative laboratory examination results and preoperative radiological and nuclear medicine findings of the patients were retrospectively recorded.

Results:

A total number of 41 patients with PHPT were divided into two groups as the Group 1 with PHPT and benign thyroid pathology (21 patients) and the Group 2 with PHPT and malignant thyroid pathology (20 patients). In Group 1, 18 and 3 of 21 patients were females and males, respectively. Group 2 included 15 male and 5 female patients. The mean age of the patients was found to be 55.6 and 53.9 years in Group 1 and Group 2, respectively. Both groups were matched for age and gender. In terms of thyroid pathology, 20 of 41 patients (48.7%) who underwent total thyroidectomy for PHPT were found to have thyroid papillary carcinoma while benign pathologic conditions were detected in 21 (51.3%) individuals.

Conclusions:

Cooccurrence of thyroid diseases and PHPT is common. Therefore, all the patients should preoperatively be evaluated for the presence of thyroid pathology to determine the technique of parathyroid surgery.

Serum Calcium and Risk of Nonmedullary Thyroid Cancer in Patients with Primary Hyperparathyroidism

Background

Clinical cases of nonmedullary thyroid carcinoma (NMTC) in combination with primary hyperparathyroidism (PHPT) have been reported occasionally. However, the clinical characteristics and risk factors of concomitant NMTC in PHPT patients remain unclear. This study aimed to assess the association between PHPT and NMTC, and evaluate the clinical characteristics and risk factors of NMTC in Chinese patients with PHPT.

Material/Methods

This was a retrospective cohort analysis. We reviewed the medical records of 155 patients who underwent surgery for PHPT in two large medical centers in China between 2009 and 2014. The clinical manifestations, biochemical abnormalities, and histological characteristics of PHPT patients were analyzed.

Results

Of the 155 patients with PHPT, 58 patients (37.4%) had thyroid nodules and 12 patients (7.7%) were ill with concomitant NMTC. PHPT patients with NMTC demonstrated significantly lower preoperative serum calcium levels compared to PHPT patients with benign thyroid nodules (p<0.05). A significantly negative association between preoperative serum calcium levels and the presence of NMTC was found in PHPT patients (p<0.05). Furthermore, ROC analysis revealed that albumin-corrected serum calcium levels <2.67 mmol/L had good capacity to differentiate the PHPT patients with NMTC from those with benign thyroid nodules.

Conclusions

Compared with the reported much lower prevalence of thyroid carcinoma in the general population, our results suggest that PHPT might be a risk factor for the malignancy of thyroid nodules; a lower level of serum calcium may predict the existence of NMTC in PHPT patients with thyroid nodules.

Surgical treatment of concomitant thyroid and parathyroid disorders: analysis of 4882 cases

The thyroid gland disease incidence in hyperparathyroidism (HPT) is higher than the incidence of thyroid disease in general population. Likewise, HPT is more frequent in patients primary admitted due to thyroid disease, than in general population. The aim of this study was to determine the incidence and clinical characteristics of concomitant HPT and thyroid disease, based on a single center experience. From 2009 to 2014, a total of 4882 patients underwent thyroidectomy and/or parathyroidectomy at the Center for Endocrine Surgery, Belgrade. We reviewed the database to find out indications for surgery, clinical characteristics, operative and histopathological findings. Out of 4033 patients, who underwent thyroidectomy, in 114 cases (2.8 %) parathyroidectomy was simultaneously performed. Out of these 114 patients, 42 patients (37 %) had normocalcemic HPT. Among 849 patients primary operated due to HPT, thyroid gland disease that required surgery was found in 224 (26.4 %). In patients primary seen for HPT, thyroid cancer was found in 22 (9.8 %), Hashimoto's thyroiditis in 41 (18.3 %) and micropapillary carcinoma in 36 cases (16.1 %). Due to residual or recidivant HPT, 16 patients (15 who primary underwent parathyroidectomy and 1 primary seen for thyroid disease) needed a reoperation. There are a considerable number of patients with concomitant thyroid and parathyroid disease; this justifies the routine analyses of calcemia and PTH level in patients preparing for thyroidectomy, and sets up the ground for the thyroid investigations in HPT.

Comparison of single photon emission CT (SPECT) with SPECT/CT imaging in preoperative localization of parathyroid adenomas: A cost-effectiveness analysis

BACKGROUND

Controversy exists regarding the superiority of single photon emission CT (SPECT)/CT over SPECT for preoperative localization of parathyroid adenomas in primary hyperparathyroidism (PHPT), as well as the cost-effectiveness.

METHODS

A retrospective review was undertaken of patients undergoing surgery for PHPT from January 2009 to August 2014. Ultrasound and SPECT (ultrasound-SPECT) or SPECT/CT (ultrasound-SPECT/CT) were performed for each patient. Sensitivity and positive predictive value (PPV) of each modality were calculated. Cost-effectiveness was determined by an incremental cost-effectiveness ratio (ICER) analysis.

RESULTS

Two hundred fifty-nine patients with 266 parathyroid adenomas were included in the study. Lateralization sensitivity and PPV of ultrasound-SPECT were 85.1% and 98.2%, respectively. The lateralization sensitivity and PPV of ultrasound-SPECT/CT were 86.9% and 99.4%, respectively. A cost of $2499.22 (CAD) per additional parathyroid adenoma detection by ultrasound-SPECT/CT was determined from the ICER analysis.

CONCLUSION

Similar sensitivities and PPVs were observed between ultrasound-SPECT and ultrasound-SPECT/CT in preoperatively lateralizing parathyroid adenomas, with relatively equivalent cost-effectiveness. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2062-E2065, 2016.

Thyroid pathologies accompanying primary hyperparathyroidism: a high rate of papillary thyroid microcarcinoma

OBJECTIVE

Thyroid pathologies and non-medullary thyroid cancer often accompany primary hyperparathyroidism (PHPT). The purpose of this study was to examine the association between thyroid diseases, especially micropapillary thyroid cancer, with PHPT.

MATERIAL AND METHODS

Data regarding 46 patients who were operated on with a diagnosis of PHPT at Inonu University Faculty of Medicine, General Surgery Clinic between June 2009 and March 2013 were retrospectively analyzed. Age, gender, levels of preoperative calcium, parathyroid hormone and phosphorus, and the histopathological results of the removed parathyroid and thyroid tissues were evaluated. All of the patients had a preoperative diagnosis of PHPT and there was no history of radiation to the head and neck region in any of the patients.

RESULTS

Out of the 46 patients who were operated on for PHPT, 39 were female and 7 were male. The mean age was 52.8 years (25-76). Simultaneous thyroidectomy was performed in 35 patients (76.1%) due to an accompanying thyroid disorder. Papillary microcarcinoma was detected in 5 of these 35 (10.9%) patients who underwent thyroidectomy, two of which (40%) were multifocal tumors. The benign thyroid pathologies detected in the remaining 30 (65.2%) cases included lymphocytic thyroiditis in 3, Hashimoto thyroiditis in 1, follicular adenoma in 3 (two of which was Hurtle cell), and nodular colloidal goiter in 23 patients. The preoperative serum phosphate level was significantly higher in the group with papillary thyroid microcarcinoma (p=0.013).

CONCLUSION

In regions where goiter is endemic, thyroid diseases and thyroid papillary microcarcinoma occur in association with PHPT at a higher rate compared to the normal population. Therefore, we believe that patients who are planned for surgery due to PHPT should be thoroughly investigated for the presence of any concomitant malignant thyroid pathologies in the preoperative period. It should also be kept in mind that patients with high blood serum phosphate values may have an increased risk of papillary thyroid microcarcinoma.

Incidental finding of papillary thyroid carcinoma with BRAFV600E mutation in a patient with coexistent primary hyperparathyroidism and Graves' hyperthyroidism

The simultaneous occurrence of hyperthyroidism and hyperparathyroidism was previously reported to be rare, but it was recognised more and more clearly by effective evaluations. Recent studies also mentioned the coexistence of parathyroid adenoma and papillary thyroid carcinoma (PTC). The potential mechanism is still unknown. We report a case of a 46-year-old man coexisted with primary hyperparathyroidism, Graves' hyperthyroidism and occult PTC. The patient had a 6-month history of polyphagia and irritability. Blood examinations showed elevated serum calcium and parathyroid hormone levels. Serum phosphate was lower. Thyroid function evaluation indicted Graves' hyperthyroidism. Ultrasound showed a solitary hyperchoic thyroid nodule in the right gland. Parathyroid radioisotope scanning found a mild enhancement of 99mTc absorption in the lower part of the right parathyroid gland. A surgical exploration was carried out and the parathyroid adenoma resection was performed. An occult micro-PTC with BRAF(V600E) mutation was also detected.

Surgeon-driven thyroid interrogation of patients presenting with primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (pHPT) is an increasingly prevalent disease affecting all age groups. The authors sought to determine the impact of a "thyroid interrogation" practice protocol on the surgical treatment of patients with the diagnosis of pHPT referred to a single surgeon.

STUDY DESIGN

We performed a retrospective review of prospectively gathered data on parathyroidectomy (PTX) patients undergoing both a prospective clinical thyroid evaluation and thyroid ultrasound between January 2008 and October 2012.

RESULTS

Only 5.6% of 468 PTX patients were referred to a single surgeon for both parathyroid and thyroid surgical evaluation; 31% of patients had known pre-existing thyroid disease (hypothyroidism most commonly), and 22% of patients had palpable thyroid abnormalities unrecognized in 67% of cases by the referring physician. Of the 468 patients, 2.6% had a history of classic head and neck radiation exposure, 2.6% a history of radio-iodine treatment, and 3% a family history of thyroid cancer. Thyroid abnormalities were found on ultrasound in 61% of patients, and 26% of patients underwent thyroid biopsies. Parathyroid and thyroid surgery was combined for 18.4% of patients; indications included obstructive symptoms (3.2%), hyperthyroidism (0.9%), intraoperative findings (5.1%), and concern for malignancy (9.2%). Malignancy was diagnosed in 23 patients (4.9%), only 8 of whom had been referred for thyroid evaluation.

CONCLUSIONS

The majority of patients referred for PTX had evidence of thyroid pathology. For an important minority of these patients, benign and malignant disease was identified that merited surgical treatment at the time of PTX. We recommend comprehensive thyroid evaluation of patients referred for PTX.

Highly efficient localization of pathological glands in primary hyperparathyroidism using contrast-enhanced ultrasonography (CEUS) in comparison with conventional ultrasonography

INTRODUCTION

Preoperative detection of parathyroid gland adenoma in the presence of primary hyperparathyroidism (pHPT) represents a diagnostic challenge. We present the first prospective study with contrast-enhanced ultrasonography (CEUS) as the central diagnostic tool for the preoperative localization of parathyroid gland adenoma in pHPT in comparison with conventional ultrasonography.

METHODS

Between July 2010 and December 2011, 75 consecutive patients underwent surgery for pHPT. In all patients, conventional ultrasonography and CEUS were performed prospectively for localization of pathological parathyroid glands. Twenty-five patients suffered from a concomitant goiter (CG), and 12 patients had undergone previous neck surgery due to thyroid pathologies. The sensitivity of both diagnostic tools was analyzed in comparison with intraoperative and histological findings.

RESULTS

CEUS had a sensitivity of 97% for the detection of the correct quadrant of the pathological parathyroid gland and of 99% for the correct side in comparison with 70% for conventional ultrasonography. In multivariate regression analysis, CG, gland size, and body mass index had a relevant impact on incorrect findings by conventional ultrasonography as compared with CEUS. Follow-up with a minimum of 6 months after surgery showed normal serum levels of calcium and PTH in all 75 patients.

CONCLUSIONS

CEUS represents a highly reliable, noninvasive and nonradioactive diagnostic tool for localization of pathological parathyroid glands in patients with pHPT. Even in the presence of CG, previous neck surgery, or double adenomas, CEUS has a high sensitivity.

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.

Incidence of concomitant hyperparathyroidism in patients with thyroid disease requiring surgery

BACKGROUND

Thyroid disease and hyperparathyroidism (HPT) are among the most common endocrine disorders, however, their association has not been well established. The aim of the present study was to determine the incidence of concomitant HPT in patients with thyroid disease requiring surgery, because a single definitive surgery should ideally be performed.

METHODS

We retrospectively reviewed a prospectively maintained database of patients who underwent thyroidectomy at a single institution. Data collected included the patients' initial indication for surgery, preoperative workup, and operative findings.

RESULTS

Of the 1,049 patients who underwent thyroidectomy, 56 (5%) had concomitant HPT and underwent simultaneous parathyroidectomy. Of these 56 patients, 36 initially presented with thyroid disease and 20 with HPT. The mean age was 59 ± 2 years, and 79% were women. The mean preoperative calcium and parathyroid hormone levels were elevated at 10.4 ± 0.1 mg/dL and 87 ± 7 pg/mL, respectively. Most of these patients had primary HPT (n = 54, 96%). Of the 36 patients presenting initially with thyroid disease, 26 had an elevated calcium or parathyroid hormone value and were preoperatively diagnosed with HPT. The remaining 10 patients had normal laboratory findings; however, a pathologically enlarged parathyroid gland was found at thyroidectomy. The overall cure rate for HPT within our series was 96%.

CONCLUSION

The incidence of concomitant HPT in patients with thyroid disease requiring surgery is significant at 5%. Recognition of concurrent disease is important, because it allows for a single definitive surgery to treat both pathologies.

Preoperative thyroid ultrasound is indicated in patients undergoing parathyroidectomy for primary hyperparathyroidism

BACKGROUND

Primary hyperaparathyroidism (pHPT) is often accompanied by underlying thyroid pathology that can confound preoperative parathyroid localization studies and complicate intra-operative decision making. The aim of this study was to examine the utility of preoperative thyroid ultrasonography (US) in patients prior to undergoing parathyroidectomy for pHPT.

METHODS

An Institutional Review Board approved prospective study was undertaken from January 2005 through July 2008. All patients with pHPT meeting inclusion criteria (n=94) underwent preoperative thyroid ultrasound in addition to standard (99m)Tc-sestamibi scintigraphy for parathyroid localization. Demographics, operative management and final pathology were examined in all cases.

RESULTS

Fifty-four of the 94 patients (57%) were noted to have a thyroid nodule on preoperative US, of which 30 (56%) underwent further examination with fine needle aspiration biopsy. Alteration of the operative plan attributable to underlying thyroid pathology occurred in 16 patients (17%), with patients undergoing either total thyroidectomy (n=9) or thyroid lobectomy (n=7). Thyroid cancer was noted in 33% of patients undergoing thyroid resection, and 6% of all patients with HPT.

CONCLUSIONS

The routine utilization of preoperative thyroid ultrasound in patients prior to undergoing parathyroid surgery for pHPT is indicated. The added information from this non-invasive modality facilitates timely management of co-incidental, and sometimes malignant, thyroid pathology.

[Hyperparathyroidism, goiter and well-differentiated thyroid carcinoma. A common association with diagnostic implications]

OBJECTIVE

To analyze thyroid gland disease incidentally found in patients undergoing surgery for hyperparathyroidism and to compare the frequency of nonmedullary thyroid carcinoma among different hyperparathyroidism varieties.

PATIENTS AND METHOD

We retrospectively reviewed 124 clinical records of patients who underwent surgery for hyperparathyroidism by a single surgeon from January 1998 to June 2006.

RESULTS

There were 105 women (84.7%) and 19 men (15.3%). The mean age was 59.7 +/- 15.66 years old. Of these, 115 (92.7%) were diagnosed with primary hyperparathyroidism and 9 (7.3%) with renal hyperparathyroidism. In the primary hyperparathyroidism group, 3 patients (2.6%) had received neck irradiation compared with none in the renal hyperparathyroidism group. Thyroid gland surgery was performed simultaneously in 43 patients (34.7%), 40 (34.8%) of them belonging to the first group and three (33.3%) to the second group (p = 1.00). Among the 115 patients operated on for primary hyperparathyroidism, 6 papillary thyroid carcinomas (5.2%) were found and 2 (22.2%) were found among the 9 patients with renal hyperparathyroidism, but this difference was not statistically significant (p = 0.105).

CONCLUSIONS

An incidental finding of thyroid disease in patients undergoing surgery for hyperparathyroidism is fairly frequent but no more so than that found in autopsy series. No statistically significant differences were found between primary and renal hyperparathyroidism in the prevalence of papillary thyroid carcinoma. Currently, neck irradiation does not seem to be a clinically significant factor in this issue. The high prevalence of thyroid disease in the general population warrants systematic neck ultrasound before hyperparathyroidism surgery.

Preoperative localization and minimally invasive management of primary hyperparathyroidism concomitant with thyroid disease

The coexistence of thyroid diseases with primary hyperparathyroidism (PHPT) can present a challenge in the clinical diagnosis and management for these patients. This study aims to determine the frequency of coexisting thyroid gland lesions in a consecutive series patients with PHPT, and to analyze the clinical features, diagnosis and treatment of these patients. Twenty-two cases of a total of 52 PHPT patients who had synchronous thyroid and parathyroid pathology were surgically managed in this study. Thirteen patients had ipsilateral thyroid nodules, and 9 patients had thyroid nodules in contralateral or bilateral side. Seven patients underwent direct parathyroidectomy and hemithyroidectomy via a mini-incision (about 3 cm), while other 15 procedures were converted to Kocher incision. Seventeen nodular goiter (32.7%), 2 thyroiditis (3.8%), 2 thyroid adenoma (3.8%) and 1 thyroid carcinoma (1.9%) coexisting with parathyroid adenoma were pathologically diagnosed. The sensitivity of preoperative ultrasonography (US) and methoxy-isobutyl-isonitrile (MIBI) scintigraphy for parathyroid lesions was 63.6% and 85.7%; and the overall positive predictive values for MIBI and US were 100% and 95.5% respectively. A high incidence of thyroid diseases that coexisted with PHPT in literatures was briefly reviewed. Our study illustrated the need for clinical awareness of concomitant PHPT and thyroid disease. A combination of US, computed tomography (CT) and MIBI scintigraphy would be recommended for preoperative localization of enlarged parathyroid adenoma and for evaluation of thyroid lesions. Synchronous treatment of associated thyroid abnormalities is desirable, and open minimally invasive surgical approach with additional resection of isolated ipsilateral thyroid nodules is possible in some of these patients.

Incidental Parathyroid Adenoma Mimicking Tumor Recurrence in a Patient With Follicular Thyroid Carcinoma

We report the case of a 59-year-old woman with a history of follicular thyroid cancer who had reoperation for suspected local tumor recurrence as laboratory (tumor marker), imaging findings (ultrasound, I-131 scintigraphy and Tc-99m-MIBI scintigraphy), and also fine needle aspiration (FNA) cytology were equivocal. However, postoperative histopathology revealed a parathyroid adenoma.