Usefulness of preoperative ultrasonographic localization for diagnosis of a rare disease: Intrathyroid parathyroid lesions

Recurrent secondary hyperparathyroidism due to a gradually increasing intrathyroidal parathyroid adenoma in a fifth parathyroid gland of a patient undergoing long-term haemodialysis: Road to evil

BACKGROUND

An intrathyroidal parathyroid adenoma (IPA) is a very rare cause of recurrent hyperparathyroidism after parathyroidectomy in patients undergoing long-term haemodialysis. An IPA is often difficult to localize preoperatively, making diagnosis and treatment challenging. We herein report a rare case of recurrent hyperparathyroidism due to a gradually increasing IPA in a fifth parathyroid gland.

CASE PRESENTATION

A 24-year-old Chinese woman had end-stage renal disease secondary to chronic glomerulonephritis and started regular haemodialysis in March 2007. She was diagnosed with renal hyperparathyroidism as indicated by elevated parathyroid hormone and calcium levels in 2011. One year later, the parathyroidectomy with right forearm autotransplantation was performed in January 2012. Pathology revealed parathyroid nodular hyperplasia in four of the nodules. Twelve years after surgery, the nodule in the right thyroid was detected by multiple imaging modalities. In addition to the recurrence of renal hyperparathyroidism, the nodule gradually increased in size. Total right thyroid lobectomy was performed, and the patient was diagnosed with an IPA. At the 3-month follow-up examination, she had no signs of recurrence despite regular haemodialysis, and her PTH and serum calcium levels were stable.

CONCLUSIONS

This is a rare case of recurrent hyperparathyroidism due to a gradually increasing fifth parathyroid gland in a patient who underwent long-term haemodialysis after parathyroidectomy. We suggest vigilant postoperative monitoring for prompt and early identification of culprit parathyroid lesions, even if the four parathyroid glands have been dissected.

The value of ultrasound in combination with 99mTc-MIBI imaging department of ultrasound medicine, for the diagnosis of ectopic parathyroid glands in the thyroid gland in patients with secondary hyperparathyroidism

To investigate the value of preoperative ultrasound combined with 99mTc-MIBI imaging for the diagnosis of ectopic intrathyroid parathyroid gland (ETPG) in patients with secondary hyperparathyroidism (SHPT). One hundred and eleven patients with SHPT who underwent total parathyroidectomy plus forearm transplantation from January 2015 to January 2022 in the Third Hospital of Hebei Medical University were selected. All patients underwent routine preoperative ultrasonography and 99mTc-MIBI imaging, and with pathological diagnosis as the gold standard, the clinical data of ETPG patients were selected, including clinical manifestations, laboratory tests, preoperative ultrasonography and 99mTc-MIBI imaging for localization and diagnosis, intraoperative exploration and postoperative pathology, and postoperative follow-up. To analyze the ultrasound manifestations of preoperative parathyroid hyperplasia and the results of 99mTc-MIBI imaging in patients with ETPG. Among 111 patients with SHPT, there were 5 patients with ETPG, 1 male and 4 females with a mean age of (45.00 ± 5.05) years, and 6 ectopic parathyroid glands were located in the thyroid gland. The incidence of ETPG was 4.5% (5/111), 4 were detected by ultrasound, 2 were not detected with a diagnostic accuracy of 66.7% (4/6), 3 were positive for 99mTc-MIBI imaging, 3 were negative with a diagnostic accuracy of 50.0% (3/6). Among them, one was not detected by ultrasound, but was positive for 99mTc-MIBI imaging, 2 with negative 99mTc-MIBI imaging, but all were detected by ultrasound, and one with negative 99mTc-MIBI imaging was detected by ultrasound but misdiagnosed as a thyroid nodule. A total of 5 ETPGs were detected by ultrasound combined with 99mTc-MIBI imaging, with a diagnostic accuracy of 83.3% (5/6). Patients' postoperative serum calcium and serum parathyroid hormone (PTH) levels were normalized or significantly decreased from preoperative levels. Ultrasound combined with 99mTc-MIBI imaging can achieve higher accuracy than either examination alone in the preoperative localization and diagnosis of ETPG in SHPT patients.

Intrathyroidal parathyroid adenomas: Scoping review on clinical presentation, preoperative localization, and surgical treatment

Intrathyroidal parathyroid adenomas (IPAs) are a rare cause of primary hyperparathyroidism. They are often difficult to localize preoperatively and intraoperatively, making diagnosis and treatment challenging. Current data on IPAs are sparse and fragmented in the literature. This makes it difficult to compare the effectiveness of different imaging and surgical techniques. To address this issue, this scoping review maps the literature on IPAs, focusing on four domains: clinical presentation, current localization methods, different surgical techniques, and histopathological features. A search of MEDLINE, Embase, and the Cochrane Library was conducted, with 19 studies meeting the inclusion criteria. The characteristics of IPAs on ultrasound, fine-needle aspiration, CT, MRI, sestamibi-based techniques, and selective venous sampling are summarized. Emerging imaging modalities, including autofluorescence, are introduced. Surgical methods and intraoperative factors that correlate with high success rates for removal are highlighted. This review also identifies gaps in knowledge to guide further research into this area.

Disability Weights and Years Lived with Disability of Depression with and Without Suicidality

Background

Globally, depression is a silent epidemic, and more than 350 million people suffer from depression. For a long time, the belief prevailed that children and young people cannot suffer from depressive disorders, and depression is slowly becoming one of the leading health problems among the young population.

Objective

This research aims to determine the mental health disorders burden attributed to depression, anxiousness, and fear with and without suicidal ideation among youth in Bosnia and Herzegovina.

Methods

A prospective cross-sectional study was performed as screening of depression by Hamilton standardized screening instrument from May 3, 2018, to April 4, 2019, among young people, students in secondary schools, and the Faculty of Pharmacy and Medical Faculty of the University of Tuzla in the most populous Tuzla Canton in the Federation of Bosnia and Herzegovina. In achieving the research goals, we expressed the burden attributed to depression with and without suicidality, anxiousness, and fear as Disability Weight (DW) and Years Lived with Disability (YLD). For the population level, YLD was calculated by multiplying DW by the prevalence rate of depression, anxiousness, and fear per thousand of the population (YLD= DW x prevalence/1000), and DW was adjusted for suicidality.

Results

The participants' ages ranged from 16 to 24 years, with a mean of 20,6 ± 1,9 years. The Body mass index (BMI) of 21,9 ± 2,7 is the recommended reference value of 18.5-24.9 kg/m2. The depression score of all participants ranged from 0 to 32 with a mean of 7.4± 6.3, which for our population of respondents at the sample level implies entry into the zone of presence of depressive symptoms. Descriptive statistics and differences per gender in sociodemographic variables (age, education state, and secure monthly existence); and modified factors attributed to satisfaction needs (life satisfaction, hope for the future, support from person of influence). Most participants belong to the age group 19-21 years, 71,44% (n=180), and the same 14,28% (n=36) other age groups (16-18 and 22-24 years), and sixty-two percent of participants are university students, and twenty percent are university failures.

Conclusion

Based on our findings, the very high burden of depression in Bosnia and Herzegovina was found greatly not recognized and unsolved problem among the young population aged 16-24 years. Recognizing and screening depression in young people is the first step to prevention.

A Silent Non-thyroidal Adenoma in the Thyroid

The surgeon needs to assess clinically significant thyroid nodules as they may represent aggressive forms of thyroid cancer or ectopic parathyroid glands. We discuss one such unusual nodule in the thyroid.

The Value of Preoperative and Intraoperative Ultrasound in the Localization of Intrathyroidal Parathyroid Adenomas

AIM

Intrathyroidal parathyroid adenoma (IPA) is rare and may easily be mistaken for thyroid nodule in ultrasonography. The aim of this study was to investigate the characteristic features of IPA and explore the value of preoperative and intraoperative ultrasound in the diagnosis and localization of IPA.

METHODS

13 of 216 patients who were found to have intrathyroidal parathyroid lesions underwent parathyroidectomy in our hospital because of PHPT. According to the relationship between parathyroid adenoma and thyroid gland, parathyroid adenoma was divided into extra-thyroid type or intra-thyroid type (partial or complete) and the results were compared with surgical and histopathological reports as gold standard. The sonographic features of intrathyroidal parathyroid lesions were analyzed retrospectively.

RESULTS

A total of 12 intrathyroidal lesions showed profoundly hypoechoic solid nodules with well-defined border, abundant blood flow and polar feeding vessels originating from the superior or inferior thyroid artery (92.3%, 12/13). These nodules were finally confirmed as IPA (or IPAC) after surgery. Polar feeding vessel was not detected in one case of parathyroid hyperplasia confirmed by pathology (7.7%, 1/13). 12 cases were diagnosed and localized on ultrasonography before operation and 10 cases were localized on Tc-99m MIBI SPECT/CT.

CONCLUSIONS

The color Doppler ultrasound findings of IPA were confirmed as profoundly hypoechoic nodules with clear boundary and abundant internal blood flow. The presence of polar feeding vessels which originate from thyroid artery were identified as characteristic features of US for IPA. Preoperative and intraoperative ultrasound could be helpful in the localization and treatment of intrathyroidal parathyroid diseases.

First ever case report of co-occurrence of hobnail variant of papillary thyroid carcinoma and intrathyroid parathyroid adenoma in the same thyroid lobe

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First reported case of hobnail variant of papillary thyroid cancer and Intrathyroid parathyroid adenoma occurring within same thyroid lobe.

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Next-generation sequencing of the mutation spectrum of hobnail variant of papillary thyroid cancer showed BRAFV600E mutation.

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Studies that define other molecular abnormalities may be useful as therapeutic targets.

Introduction

The hobnail variant of papillary thyroid cancer (PTC) is rare. Intrathyroid parathyroid adenoma (ITPA) is also rare. Co-ocurrence of PTC and ITPA in the same thyroid lobe is extremely rare. Likewise, primary hyperparathyroidism with such non-medullary thyroid carcinoma is rare. The specific molecular profile of hobnail PTC (HPTC) is different from the classic, poorly differentiated and anaplastic variants and may contribute to its aggressive behavior. HPTC’s genetic profile remains unclear.

Presentation of case

A 61-year-old woman presented to our endocrine clinic with generalized aches, bone pain, polyuria, and right neck swelling of a few months’ duration. Laboratory findings revealed hypercalcemia and hyperparathyroidism. Ultrasound of the neck showed 4.6 cm complex nodule within the right thyroid lobe. Sestamibi scan suggested parathyroid adenoma in the right thyroid lobe. Fine-needle aspiration (FNA) revealed atypical follicular lesion of undetermined significance. She underwent right lobectomy, which normalized the intraoperative intact parathyroid hormone levels. Final pathology with immunohistochemical stains demonstrated HPTC and IPTA (2 cm each). Next-generation sequencing investigated the mutation spectrum of HPTC and detected BRAFV600E mutation.

Conclusions

A parathyroid adenoma should not exclude the diagnosis of thyroid carcinoma. Thyroid evaluation is needed for patients with primary hyperparathyroidism to prevent missing concurrent thyroid cancers. Cytomorphologic features to distinguish thyroid from parathyroid cells on FNA cytology must be considered. Immunohistochemical stains are important. BRAFV600E is the most common mutation in HPTC. This is possibly the first reported case of HPTC and ITPA co-occurring within the same thyroid lobe. Studies that define other molecular abnormalities may be useful as therapeutic targets.