Incidental thyroid nodules in patients with primary hyperparathyroidism

A case of normocalcemic primary hyperparathyroidism presenting with a mass in the oral cavity and accompanying incidental papillary thyroid carcinoma

Hyperparathyroidism (HPT) is an endocrine disorder characterized by high secretion of parathyroid hormone. Brown tumor is one of the skeletal manifestations of HPT. Its overall prevalence is low (about 0.1%). Involvement of facial bones is extremely rare. The mandible is involved in 4.5% of cases. Primary HPT (PHPT)with vitamin D deficiency worsens the clinical course. Parathyroid adenoma is detected in ectopic places with a rate of 8.5%. 0.2% is intrathyroidal, 2% is located in different neck regions, 4.1% is in the upper mediastinum, and 2.2% is in the lower mediastinum. The prevalence of papillary thyroid cancer (PTC) in PHPT patients has been reported to range from 2% to 15%. In the literature, incidentally detected papillary thyroid cancer in patients with hyperparathyroidism was detected in patients who underwent total thyroidectomy associated with intrathyroidal parathyroid adenoma. In this article, we present a case of incidental papillary thyroid carcinoma with ectopic parathyroid adenoma accompanied by severe vitamin D, and diagnosed during accompanying surgery following a brown tumor was considered after primary hyperparathyroidism was detected. However, the patient was admitted with a mass in the oral cavity, diagnosed before as a pyogenic granuloma with a delayed diagnosis without considering brown tumor because it was normocalcemic. It is the first case in the literature of papillary thyroid carcinoma detected incidentally with ectopic parathyroid adenoma in the thyrothymic region.

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.

Incidental Papillary Thyroid Cancer Identified During Parathyroidectomy

Current treatment guidelines recommend surgical excision of papillary thyroid carcinoma. However, the precise surgical treatment, including thyroid lobectomy, total thyroidectomy, and the need for neck dissection, is dictated by disease extent and tumor cytology. Incidental papillary thyroid carcinoma discovered during another surgery therefore presents a surgical conundrum due to lack of information. Surgeons must consider short- and long-term surgical morbidities, as well as individual patient factors, when deciding how to treat an unexpected thyroid carcinoma.

Long-term therapeutic outcomes of papillary thyroid carcinoma with concomitant hyperparathyroidism: A single center case-control study

Background

Papillary thyroid carcinoma occasionally presents with concomitant hyperparathyroidism; however, the clinical significance has not been well established. This study aimed to evaluate the long-term cancer prognosis following a multimodality therapy.

Methods

We conducted a case-control study using prospectively maintained data from a medical center thyroid cancer database between 1980 and 2013. The study cohort comprised patients with concomitant papillary thyroid carcinoma and hyperparathyroidism. Patients with papillary thyroid carcinoma only were matched using the propensity score method. Therapeutic outcomes, including the non-remission rate of papillary thyroid carcinoma and patient mortality, were compared.

Results

We identified 27 study participants from 2537 patients with papillary thyroid carcinoma, with 10 patients having primary hyperparathyroidism and 17 having renal hyperparathyroidism. Eighty-five percent of the cohort was found to have tumor–node–metastasis stage I disease. During a mean follow-up of 7.7 years, we identified 3 disease non-remission and 4 mortality events. The non-remission risk did not increase (hazard ratio [HR], 1.66; 95% confidence interval [CI], 0.43–6.40; p = 0.47); however, the overall mortality risk significantly increased (HR, 4.43; 95% CI, 1.11–17.75; p = 0.04). All mortality events were not thyroid cancer related, including two identified cardiovascular diseases.

Conclusions

Patients with papillary thyroid carcinoma who present with concomitant hyperparathyroidism are usually diagnosed at an early cancer stage with compatible therapeutic outcomes. However, hyperparathyroidism-related comorbidity may decrease long-term survival.

The role of ultrasound in the diagnosis of the coexistence of primary hyperparathyroidism and non-medullary thyroid carcinoma

BACKGROUND

The coexistence of primary hyperparathyroidism(PHPT) and papillary thyroid cancer(PTC) is a known entity; it is a rare and complicated setting for diagnostic imaging.

METHODS

After reviewing clinical data of 112 patients who had been treated for PHPT in our facility between January 2015 and December 2017, we identified 7 non-medullary thyroid carcinoma (NMTC) (6.25%). All of them had taken an ultrasound scan and undergone operation. In addition, we have also reviewed relevant reports from other facilities addressing PHPT and NMTC (Mainly PTC).

RESULTS

The 7 NMTCs were all pathologically confirmed PTC in our study, and they consisted of 6 parathyroid adenomas and 1 parathyroid carcinoma. 1 of the 7 patients had 2 malignant PTC nodules with neck lymph node metastasis, the rest 6 had single-focal PTC. Processing previous report data supported an association between PHPT and PTC, although the coexistence of PHPT and PTC is rare, but it does happen. Ultrasound, as an effective examination, would help screen the simultaneous lesions before operation, thus to avoid second surgery if not observed for both diseases at initial stage.

CONCLUSIONS

Ultrasound is a necessary choice for preoperative localization, because it has the ability to simultaneously examine the thyroid and parathyroid lesions.

Characterization of Thyroid Nodules by 4-Dimensional Computed Tomography: Initial Experience

OBJECTIVE

We aimed to evaluate the use of 4-dimensional computed tomography (4DCT) for characterization of thyroid nodules.

METHODS

Our study drew from 100 consecutive patients with primary hyperparathyroidism who underwent 4D parathyroid CT imaging for adenoma localization. Included subjects had tissue sampling of a thyroid nodule within 3 months of 4DCT.

RESULTS

Twenty subjects (18 women and 2 men) had thyroid nodules that were pathologically confirmed. Precontrast nodule attenuation was significantly lower in malignant nodules when compared with benign nodules (36 vs 61 HU, P = 0.05). Arterial phase and delayed phase nodule attenuations were not significantly different in malignant and benign nodules (128 vs 144 HU, P = 0.7; 74 vs 98 HU, P = 0.3).

CONCLUSIONS

Our initial experience with a small group of patients was unable to support the use of 4DCT for characterizing thyroid nodules; however, precontrast nodule attenuation was significantly lower in malignant nodules when compared with benign nodules.