Atypical presentations of parathyroid gland pathology: A pictorial review

A Deceptive Preoperative Imaging of an Ectopic Supernumerary Parathyroid Adenoma in a Secondary Hyperparathyroidism

Ectopic and supernumerary parathyroid glands in the neck is a real surgical challenge especially in multi-gland pathologies. We report a supernumerary ectopic gland at a rare site in the neck in a chronic kidney disease patient which required a re-exploration following a deceptively successful bilateral neck dissection.

Percentage arterial enhancement on 2D CT in the diagnosis of primary hyperparathyroidism: A prospective validation study and potential pitfalls

BACKGROUND

Parathyroid lesions are identified by subjective enhancement and washout patterns on computed tomography (CT). We have previously proposed "percentage arterial enhancement" (PAE) as an objective index and now aim to validate its performance prospectively.

METHODS

Dual-phase CT was performed in 40 consecutive primary hyperparathyroidism patients. PAE was calculated as [{arterial phase Hounsfield unit (HU)-unenhanced phase HU}/unenhanced phase HU] × 100. PAE > 128.9% was considered parathyroid.

RESULTS

PAE had 94.2% sensitivity, 100% positive predictive value (PPV) in lateralization, and sensitivity and PPV of 93.9% in quadrant localization of single-gland disease. PAE failed to identify two lesions: an intrathyroidal parathyroid carcinoma in the background of multinodular goiter and another lower enhancing cystic parathyroid adenoma. PAE had 60% sensitivity, and 100% PPV to identify multigland disease. The mean effective dose was 2.74 mSV.

CONCLUSIONS

PAE is a specific CT index for parathyroid lesions with less radiation exposure. Areas of caution include intrathyroidal and cystic lesions.

Primary Hyperparathyroidism in the Common Orthopaedic Practice

An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.

Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.

Primary Hyperparathyroidism in the Common Orthopaedic Practice

An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.

Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.

Acute hyperparathyroid crisis: ectopic submandibular parathyroid gland the culprit

Parathyroid exploration via a focused approach or bilateral neck exploration should be considered in the management of all types of hyperparathyroidism. Eutopic and ectopic, single or multiple glands can pose challenges to the surgeon and available preoperative imaging modalities may not be equally applicable or appropriate in all cases. We report an interesting case of parathyroid surgery where the patient presented with a rare ectopic adenoma in the form of a hyperparathyroid crisis.

Safety and effectiveness of reoperation for persistent or recurrent drug refractory secondary hyperparathyroidism

Background

Drug-refractory secondary hyperparathyroidism (SHPT) is the most common complication in patients with chronic renal failure (CRF). Although surgery is the most effective and safe method for drug-refractory SHPT, the condition may persist or recur after the primary surgery, and reoperation is often required in these patients. The purpose of our current study was to evaluate the safety and effectiveness of reoperation for drug-refractory SHPT.

Methods

The clinical data of 15 patients requiring reoperation after a surgery for drug-refractory SHPT in our hospital from 2010 to 2019 were retrospectively analyzed. Changes in biochemical markers including intact parathyroid hormone (iPTH), blood calcium (Ca), blood phosphorus (P), alkaline phosphatase (ALP), and blood calcium phosphorus product (Ca*P) were compared before and after the surgery, and the effectiveness and complications of the reoperation were summarized.

Results

The reoperation was successful in all the 15 patients after a single attempt. Routine pathological examinations identified a total of 25 parathyroid glands, of which 10 were in the neck in situ, 5 were ectopic in the neck, and 10 were in the forearm. The ectopic parathyroid glands were located inside the thyroid gland (n=1), anterior superior mediastinum (n=1), or thymus (n=3). Surgical treatment significantly improved clinical symptoms such as skin pruritus and bone pain. Blood iPTH, Ca, P, ALP, and Ca*P were significantly reduced (P<0.05 or P<0.01) after surgery. Hypothyroidism occurred in 1 patient; 4 patients undergoing orthotopic neck surgery developed transient hoarseness, which were alleviated within 6 months; no severe complications such as bleeding or death were noted. No recurrence occurred during the 6-month follow-up.

Conclusions

Reoperation is safe and effective for drug-refractory SHPT. Preoperative imaging should be performed to achieve accurate positioning, and the recurrent laryngeal nerve should be closely monitored during surgery. The purpose of the reoperation is to remove all possible parathyroid tissues to avoid recurrence.