Synchronous Parathyroid Carcinoma,Parathyroid Adenoma,and Papillary Thyroid Carcinoma in a Patient with Severe and Long-Standing Hyperparathyroidism

ObjectiveTo describe a patient presenting with the rare constellation of synchronous parathyroid carcinoma, parathyroid adenoma, and papillary thyroid carcinoma.MethodsWe summarize the clinical presentation, diagnostic work-up, surgical management, and pathologic features of our patient and review the pertinent literature.ResultsThe patient was a 59-year-old man who presented with severe clinical manifestations of long-standing primary hyperparathyroidism, a serum calcium concentration of 14.4 mg/dL, and a parathyroid hormone level of 2,023 pg/mL. He was found to have a 3.4-cm parathyroid carcinoma on the left side and a 3.2-cm papillary carcinoma in the right thyroid lobe. In addition, a 917-mg parathyroid adenoma was found on the right side.ConclusionSynchronous parathyroid and thyroid carcinomas are extremely rare. To our knowledge, our patient is the first documented case with a parathyroid adenoma in addition to synchronous parathyroid and thyroid carcinomas. The presence of concurrent parathyroid carcinoma and parathyroid adenoma can cause diagnostic confusion and should be considered in patients presenting with severe hyperparathyroidism. Any concomitant thyroid nodules must be investigated to rule out thyroid carcinoma. (Endocr Pract. 2009;15:463-468)     

Fine needle aspiration cytology of cystic parathyroid lesions. A cytomorphologic overlap with cystic lesions of the thyroid

Three cases of palpable cystic parathyroid nodules examined by fine needle aspiration (FNA) cytology are reported. Two of the three aspirates were incorrectly identified as thyroid neoplasms due to the presence of papillary clusters or microfollicles and grossly golden-brown cyst fluid. Histologic examination of these two nodules revealed partially cystic parathyroid adenomas. Aspirated material from the third patient yielded clear watery fluid, which was correctly identified as consistent with a parathyroid cyst. The diagnostic difficulties in the differentiation of parathyroid adenoma from thyroid carcinoma or adenoma are discussed, as is the utilization of assays for parathyroid hormone in making the FNA diagnosis of parathyroid lesions.     

Unusual Manifestation of Parathyroid Carcinoma in the Setting of Papillary Thyroid Cancer

ObjectiveTo describe a rare manifestation of parathyroid carcinoma in association with papillary thyroid carcinoma.MethodsWe describe the clinical history, findings on physical examination, results of laboratory studies, imaging findings, and histopathologic features of a woman with 2 previously palpable thyroid nodules and mild hypercalcemia.ResultsA 79-year-old woman presented to our endocrinology clinic for reevaluation of 2 thyroid nodules and long-standing hyperparathyroidism. She initially had undergone assessment 6 years previously, at which time an intact parathyroid hormone level was 89 pg/mL (reference range, 10 to 69) and the serum calcium concentration was 10.4 mg/dL (reference range, 8.2 to 10.2) in conjunction with normal alkaline phosphatase, creatinine, and 25-hydroxyvitamin D levels. Subsequently, she was found to have multifocal papillary thyroid cancer in the right thyroid lobe and a 5-cm parathyroid carcinoma in the left side.ConclusionSynchronous parathyroid and thyroid carcinomas are extremely rare. To our knowledge, our current case is the first documented patient with parathyroid carcinoma who had a clinical presentation consistent with longstanding mild adenoma in addition to synchronous papillary thyroid carcinoma. (Endocr Pract. 2010;16:664-668)     

Fine structure of the fetal rat thyroid and parathyroid glands at term and during prolonged gestation

Summary The fine structure of the fetal rat thyroid and parathyroid glands was studied at term and during prolonged gestation, which was induced by subcutaneous injections of progesterone to the mothers from gestational days 20 through 24. At term, the follicular and parafollicular cells of the thyroid as well as cells of the parathyroid exhibited well developed cytoplasmic organelles. Morphological changes were not detected in either of the endocrine glands during prolonged gestation. The results are discussed in relationship to 1) thyroid follicular cell activity during stress and 2) the function of thyroid parafollicular and parathyroid cells in calcium homeostasis.Supported by the Medical Research Council of Canada Grant No. MA4740.     

Parathyroid involvement in thyroid cancer: an unforeseen event

ABSTRACT: BACKGROUND: Parathyroid metastatic disease from thyroid cancer has not been studied extensively, mainly due to the need for parathyroid preservation during thyroid surgery. METHODS: We reviewed files from 1,770 patients with thyroid cancer followed up in our department and 10 patients with parathyroid metastases (0.5 %) were identified. Patient and tumor characteristics were recorded. RESULTS: Six out of ten patients had metastasis from papillary thyroid cancer, three from follicular thyroid cancer and one from anaplastic thyroid cancer. In nine patients parathyroid infiltration from thyroid cancer was found in direct contact with the thyroid cancer, and in one patient metastatic foci were observed not in continuity with the thyroid cancer. CONCLUSIONS: Parathyroid involvement, although infrequent, may occur in thyroid cancer independently of patient age and tumor size. The clinical significance of such event is not clear. The influence on disease outcome remains to be elucidated.     

Imprint cytology of parathyroid tissue in relation to other tissues of the neck and mediastinum

OBJECTIVE: To retest the hypothesis that imprint cytology may be used to reliably diagnose parathyroid tissue and, if so, to ascertain whether accuracy in this technique may be easily attained. STUDY DESIGN: Imprint preparations from 15 parathyroid, 10 thyroid, 8 lymphoreticular and 2 adipose tissue specimens were assessed blindly by two pathologists, one of whom (pathologist B) had only limited experience with endocrine tissue imprint cytology. RESULTS: Both assessors consistently distinguished parathyroid and thyroid preparations from lymphoreticular and adipose tissue preparations. While there was occasional difficulty in distinguishing between parathyroid and thyroid preparations, this was usually attributable to the scanty nature of the preparations. No single cytologic feature allowed a distinction between parathyroid and thyroid tissue. However, by considering several relatively diagnostic features collectively, pathologist B showed an increase in specificity and sensitivity rates for distinguishing parathyroid from thyroid imprints from 82% to 100% and 57% to 83%, respectively. CONCLUSION: The high accuracy rates and rapid [table: see text] learning curve shown by imprint cytology in distinguishing between different neck or mediastinal tissue types, together with its time- and cost-cutting potential, support a role for the technique in the intraoperative diagnosis of parathyroid tissue.     

Calcitonin cells and unusual follicles of the thyroid of the indian grey mongoose, Herpestes edwardsi (Geoffroy).

Histological preparations of thyroid, parathyroid and thymus glands of Herpestes edwardsi were examined for calcitonin cells. They reveal that (1) the thyroid calcitonin cells are oval, rounded and rarely elongated in shape; these cells and their nuclei are distinctly larger than those of the follicular cells and their nuclei; (2) calcitonin cells are unevenly distributed in the thyroid, with the result that certain portions of the thyroid are completely devoid of these cells; (3) on an average, calcitonin cells are in a ratio of 10-15 cells/100 follicular cells; (4) the parathyroid and thymus glands do not display calcitonin cells, and (5) the thyroid gland displays unusual follicles of two categories, (a) follicles with ciliated epithelial cells and (b) follicles with squamous epithelium.     

Nodule thyroïdien bénin fixant le 99mTc-MIBI

ObjectivesTo illustrate a case of intense uptake of ^99mTc-MIBI on benign thyroid nodule and to recall the mechanisms of this uptake.Case presentationA patient of 25 years old had a parathyroid scintigraphy for suspected right lower parathyroid adenoma. The exam showed intense uptake of ^99mTc-MIBI at the infero-lateral region of the right thyroid lobe. Low levels of PTH prompted to perform a thyroid scintigraphy for better diagnostic orientation. The scan revealed a large cold right basilobar thyroid nodule. The patient underwent a right loboisthmectomy. The histological analysis found a 3 cm diameter vesicular adenoma with oncocytic cells of the lower pole of right thyroid lobe.Discussion/conclusion^99mTc-MIBI is used in the imaging of hyperparathyroidism. Radiotracer uptake is correlated to the parathyroid adenoma content in oxyphil cells. These cells are rich in mitochondria and retain the ^99mTc-MIBI. This radiotracer can bind also on thyroid nodules. The specificity of this uptake for the diagnosis of malignancy is low. It is relevant to the nodule's wealth in oncocytic cells. These cells possess numerous mitochondria and can sequester ^99mTc-MIBI like parathyroid oxyphil cells.     

Asymptomatic intrathyroidal parathyroid adenoma. Report of a case with a cytologic differential diagnosis including thyroid neoplasms

BACKGROUND: Intrathyroidal parathyroid neoplasms (IPNs) are uncommon tumors with an indolent clinical course. When asymptomatic, they can be incorrectly diagnosed as thyroid neoplasms on fine needle aspiration biopsy (FNAB), leading to inappropriate surgical treatment. CASE: A case of unsuspected IPN occurred in which the cytologic picture mimicked that of a thyroid neoplasm. The histologic specimen of the total thyroidectomy showed 2 adjacent intrathyroidal nodules morphologically and immunohistochemically corresponding to a parathyroid adenoma. CONCLUSION: The incidence of IPN remains controversial, especially in asymptomatic patients. On FNAB it is a possible cause of inappropriate surgery for a suspicious thyroid neoplasm (follicular or medullary carcinoma). Immunostaining for parathormone on the cytologic smear is valuable in establishing the correct preoperative diagnosis when the morphologic features are strongly suggestive of IPN.     

Parathyroid adenoma diagnosed as papillary carcinoma of thyroid on needle aspiration smears

Needle aspiration of a neck mass was performed on a 55-year-old white female with hypercalcemia. The cytologic material showed cohesive clusters of monomorphic hyperchromatic cells resembling follicular cells. Papillary formation and follicle-like arrangements suggested papillary carcinoma of the thyroid. The histopathologic section of the excised mass, however, revealed a parathyroid adenoma. The diagnostic difficulties in differentiating parathyroid adenoma from well-differentiated thyroid carcinoma are discussed. Data published in the literature emphasize similar difficulties, and it is concluded that a final diagnosis can be established only on histopathologic sections.     

Eya1 is required for the morphogenesis of mammalian thymus,parathyroid and thyroid

Eyes absent (Eya) genes regulate organogenesis in both vertebrates and invertebrates. Mutations in human EYA1 cause congenital Branchio-Oto-Renal (BOR) syndrome, while targeted inactivation of murine Eya1 impairs early developmental processes in multiple organs, including ear, kidney and skeletal system. We have now examined the role of Eya1 during the morphogenesis of organs derived from the pharyngeal region, including thymus, parathyroid and thyroid. The thymus and parathyroid are derived from 3rd pharyngeal pouches and their development is initiated via inductive interactions between neural crest-derived arch mesenchyme, pouch endoderm, and possibly the surface ectoderm of 3rd pharyngeal clefts. Eya1 is expressed in all three cell types during thymus and parathyroid development from E9.5 and the organ primordia for both of these structures failed to form in Eya1(-/-) embryos. These results indicate that Eya1 is required for the initiation of thymus and parathyroid gland formation. Eya1 is also expressed in the 4th pharyngeal region and ultimobranchial bodies. Eya1(-/-) mice show thyroid hypoplasia, with severe reduction in the number of parafollicular cells and the size of the thyroid lobes and lack of fusion between the ultimobranchial bodies and the thyroid lobe. These data indicate that Eya1 also regulates mature thyroid gland formation. Furthermore, we show that Six1 expression is markedly reduced in the arch mesenchyme, pouch endoderm and surface ectoderm in the pharyngeal region of Eya1(-/-) embryos, indicating that Six1 expression in those structures is Eya1 dependent. In addition, we show that in Eya1(-/-) embryos, the expression of Gcm2 in the 3rd pouch endoderm is undetectable at E10.5, however, the expression of Hox and Pax genes in the pouch endoderm is preserved at E9.5-10.5. Finally, we found that the surface ectoderm of the 3rd and 4th pharyngeal region show increased cell death at E10.5 in Eya1(-/-) embryos. Our results indicate that Eya1 controls critical early inductive events involved in the morphogenesis of thymus, parathyroid and thyroid.     

Multiglandular Parathyroid Carcinoma: Case Report and Review of The Literature

ObjectiveTo report the fifth case of multiglandular parathyroid carcinoma and highlight the necessity of bilateral neck exploration in some circumstances.MethodsWe report a case of simultaneous bilateral and multiglandular parathyroid carcinoma in a 48-yearold woman presenting with primary hyperparathyroidism. Ultrasonography revealed a 24-by 24-by 34-mm nodule on the right lobe of the thyroid and a 20-by 20-by 32-mm parathyroid gland inferior to the left thyroid lobe. Technetium Tc 99m sestamibi scan revealed bilateral increased uptake consistent with the parathyroid glands. She was treated with bilateral neck exploration and parathyroidectomy with en bloc resection of the adjacent thyroid lobe in the right lower gland and parathyroidectomy with resection of surrounding soft tissue in the left lower gland.ResultsThe presence of a thick fibrous capsule, invasion of surrounding tissues, trabecular and solid growth pattern without necrotic foci, and vascular invasion on pathology slides enabled the diagnosis of parathyroid carcinoma of both glands. Her calcium and parathyroid hormone levels were within normal limits during a follow-up period of 4 years.ConclusionSince surgical resection offers the only curative treatment and initial operation may be the determinant of survival, a high index of suspicion for carcinoma both clinically and intraoperatively is vital. We aim to reemphasize that bilateral neck exploration in select cases of parathyroid carcinoma should be considered if there is concrete evidence of a second tumor, since parathyroid carcinoma can coexist with hyperplasia, adenoma, or even carcinoma of other parathyroid glands. (Endocr Pract. 2011;17:e79-e83)     

Preliminary evaluation of endocrine cells in the rat respiratory tract after thyroid and parathyroid gland removal

The complete thyroid and parathyroid gland removal leads to the abrupt reduction of calcitonin, which can be a factor stimulating growth and intensified activity of APUD system cells in the respiratory tract. Thus, neuroendocrine cells in the lungs and trachea in rats after thyroid and parathyroid removal were evaluated. Paraffin specimens of the examined organs were stained with H+E and impregnated with silver. Calcitonin, synaptophysin, somatostatin, and neuronal-specific enolase were detected immunohistochemically by the use of rabbit specific antibodies. Antibodies used in the study immunostained neuroendocrine cells of the examined organs. Rats with removed thyroid and parathyroid glands presented weakened reaction compared to the control group.     

An Unusual Case of Recurrent Hyperparathyroidism and Papillary Thyroid Cancer

ObjectiveTo report an unusual occurrence of recurrent hyperparathyroidism due to papillary thyroid carcinoma.MethodsWe describe the clinical history, physical examination findings, laboratory values, imaging findings, and pathologic findings of a woman who developed recurrent hyperparathyroidism 13 years after successful parathyroidectomy.ResultsA 59-year-old woman presented to our clinic with recurrent primary hyperparathyroidism. In 1994, she presented with nephrolithiasis and underwent resection of a right superior parathyroid adenoma that resulted in clinical and biochemical cure. Her clinical course had been followed at periodic intervals, and she had been symptom-free and normocalcemic. In 2007, she again developed nephrolithiasis and was documented to have recurrent hyperparathyroidism. Imaging studies suggested a parathyroid adenoma near the right inferior pole of the thyroid. The patient had reoperative neck exploration. No obvious parathyroid adenoma was found and a right thyroid lobectomy was performed, which resulted in normalization of intraoperative intact parathyroid hormone levels, and the incision was closed. Final pathology demonstrated no parathyroid adenoma, but instead, a 1-cm papillary thyroid carcinoma that stained positive for parathyroid hormone. More than 6 months after surgery, she remains clinically and biochemically cured.ConclusionsRecurrent hyperparathyroidism occurs secondary to multiple causes. This case demonstrates the challenge a surgeon faces in managing recurrent disease and highlights a rare phenomenon of papillary thyroid cancer causing recurrent hyperparathyroidism. (Endocr Pract. 2009;15:349-352)     

Fine needle aspiration cytology in the preoperative diagnosis of ultrasonically enlarged parathyroid glands

The value of fine needle aspiration (FNA) cytology in the diagnosis of ultrasonically suspected parathyroid gland enlargements was reviewed for a six-year series of cases. In 146 patients, 277 FNA biopsies under ultrasound guidance were performed on suspected enlarged parathyroid glands. Smears were routinely stained by the Pappenheim (May-Grünwald-Giemsa) method, and the Grimelius silver stain was used to demonstrate argyrophilic granules in the cytoplasm of parathyroid cells. Diagnostic material was obtained by FNA from 121 (83%) patients, whereas the aspirates were considered inadequate for cytologic diagnosis in 25 (17%) patients. For the 121 cases with adequate FNA samples, cytology diagnosed a parathyroid origin in 80 (55%) of the 146 total patients) and a thyroid origin in 41 (28%). The cytologic-histologic correlation available for 36 patients showed a cytologic sensitivity of 86%. Parathyroid lesions are frequently treated preoperatively as a disease of the thyroid; the results of this study suggest that cytomorphologic analysis of FNA samples can demonstrate the parathyroid origin of such samples, especially when a silver stain is used in addition to the routine stain.     

Incidental Finding of Metastatic Papillary Thyroid Carcinoma in a Patient with Primary Hyperparathyroidism

ObjectiveTo report on the management of a patient with the rare concurrence of primary hyperparathyroidism and incidentally found metastatic papillary thyroid carcinoma in an adjacent lymph node.MethodsWe present a case report, including scintigraphic and histologic documentation, and a summary of the related literature.ResultsPrimary hyperparathyroidism with concomitant occurrence of nonmedullary thyroid carcinoma is rare, occurring in less than 4% of patients. We report a case of a 53-year-old woman with no prior history of endocrine disease with primary hyperparathyroidism and an incidental finding of a concurrent thyroid carcinoma. In this patient, technetium 99m scintigraphy revealed a parathyroid adenoma beneath the inferior pole of the left thyroid bed. Parathyroidectomy was performed successfully with no complications. The final pathology examination showed a large parathyroid adenoma with an incidental finding of a small adjacent lymph node containing metastatic papillary thyroid carcinoma. The patient subsequently underwent total thyroidectomy, and the pathology evaluation revealed papillary thyroid carcinoma, follicular variant.ConclusionTo our knowledge, this case of concomitant primary hyperparathyroidism and papillary thyroid cancer is unique in the way in which the diagnosis of metastatic papillary thyroid cancer was made. The presence of parathyroid adenoma should not exclude the diagnosis of thyroid carcinoma; therefore, careful thyroid evaluation should be considered for all patients with primary hyperparathyroidism. (Endocr Pract. 2007;13:380-383)     

Immunohistochemical demonstration of keratins in the cysts of thyroid glands, parathyroid glands, and C-cell complexes of the dog

Cyst structures were often detected in and around thyroid glands of the dog. The present study revealed the frequency of occurrence, the light microscopic features, and the immunoperoxidase reactions to anti-keratin and anti-19S-thyroglobulin antisera of each cyst located in parathyroid III, parathyroid IV, thymus IV, C-cell complexes, and thyroid parenchyma from 112 dogs. In each location, cysts showed characteristic features. In parathyroid III, the cysts were covered with single or pseudostratified epithelium composed of ciliated cells; whereas in parathyroid IV they were covered with keratinizing stratified squamous epithelium. In C-cell complexes, small cysts lined with small packed cells were predominant, and large cysts lined with single cuboidal cells or stratified squamous cells were also present. In thymus IV located in the close vicinity of parathyroid IV, cyst epithelium consisted of several types of cells showing variable features. In thyroid parenchyma, there were several types of cysts: some were covered with ciliated columnar cells, and others were covered with two or multilayers of small packed cells or cuboidal cells. In spite of these differences in appearance of the cysts located in different tissues, all their epithelia were immunoreactive to the keratin antisera, except for small cysts in C-cell complexes, which were regarded as immature structures. Thus, the presence of keratin filaments in epithelial cells seems to be a characteristic feature of all cysts. The lumens of each cyst contained variable amounts of amorphous materials, which showed colloid-like, flocculent, foamy, and granular features and were periodic acid-Schiff-positive in variable degrees, from weak to intense. Although the lumenal contents of the cysts in parathyroid III revealed no immunoreactivity for 19S-thyroglobulin, those in thyroid parenchyma, C-cell complexes, parathyroid IV, and thymus IV reacted strongly with the 19S-thyroglobulin antiserum.