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

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.

The Nexus of Hyperparathyroidism and Thyroid Carcinoma: Insights into Pathogenesis and Diagnostic Challenges-A Narrative Review

This review investigates the intricate relationship between hyperparathyroidism (HPT) and thyroid carcinoma (TC), aiming to elucidate their coexistence, potential pathogenetic mechanisms, and clinical implications. A systematic search strategy, employing the MeSH terms 'Hyperparathyroidism' and 'Thyroid Carcinoma', spanned publications from 2013 to 2023 across the PubMed, Web of Science, and Scopus databases. Fifteen selected articles were analyzed. Studies unanimously confirm the notable association between primary hyperparathyroidism (PHPT) and thyroid nodules/cancer, with incidences ranging from 2.8% to 47.1%. Key findings reveal a predilection for papillary thyroid carcinoma (PTC) in this association, showcasing varying tumor characteristics and gender disparities. Lower preoperative serum parathyroid hormone (PTH) levels are a potential risk factor for thyroid cancer in PHPT patients. Diverse surgical approaches and tumor characteristics between PHPT and secondary hyperparathyroidism (SHPT) cases were noted. Moreover, this review underscores the scarcity of definitive guidelines in managing concurrent PHPT and thyroid conditions, advocating for comprehensive assessments to enhance diagnostic accuracy and refine therapeutic interventions. Rare coincidental associations, as highlighted by case reports, shed light on unique clinical scenarios. In essence, this review amalgamates evidence to deepen the understanding of the interplay between HPT and TC, emphasizing the need for further research to elucidate underlying mechanisms and guide clinical management.

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.

CO-EXISTING HASHIMOTO'S THYROIDITIS DOES NOT AFFECT BONE METABOLISM IN PATIENTS WITH PRIMARY HYPERPARATHYROIDISM

Context

Primary hyperparathyroidism (PHPT) is often associated with thyroid disorders like nodular goiter, Hashimoto's thyroiditis (HT) and Graves' disease.

Objective

Our aim was to explore whether the co-existence with HT affects bone metabolism in patients with PHPT.

Design

This was a comparative cross-sectional study carried out in a tertiary inpatient endocrine center from January 2018 through December 2020.

Subjects and Methods

A total of 234 patients were diagnosed with PHPT at our endocrine center. One hundred of them were included in the study - 50 with PHPT only and 50 with PHPT and HT. Two control groups were defined: 37 with HT and 37 without PHPT and HT. Serum markers of calcium-phosphate metabolism, bone markers (RANKL, Osteoprotegerin, β-CTX, Osteocalcin) and interleukin-17A were measured.

Results

The frequency of HT among patients with PHPT was 37.6% (95% CI 31-43%) and did not differ significantly from that in the general population, 32.5% (95% CI 30-35%). Age, BMI, markers of calcium-phosphate metabolism, bone markers and interleukin-17A weren't significantly different in PHPT with and without HT or between the two control groups. The participants with PHPT had higher levels of interleukin-17A, β-CTX and Osteocalcin (p<0.05) than those without the PHPT. RANKL and Osteoprotegerin in these groups did not differ.Interleukin-17A correlated positively with serum calcium, PTH and RANKL and negatively with serum inorganic phosphate and 25(OH)D. Controlling for HT and age did not change the correlation.

Conclusions

In our study, HT has not additional effect on bone metabolism in the patients with PHPT. Higher levels of interleukin-17A in PHPT suggest a possible role in the PTH-induced bone remodeling.

Impact of autoimmune thyroiditis on primary hyperparathyroidism

Aim. Primary hyperparathyroidism (PHPT) often coexists with thyroid diseases. Current guidelines advise preoperative ultrasound (US) examination of the thyroid gland for thyroid nodular disease or concomitant malignancy but not evaluation for autoimmune thyroiditis (AIT). The impact of autoimmune thyroiditis on the clinical presentation and intraoperative course of PHPT is not clear. Material and methods. We retrospectively assessed the medical records of 21 patients with PHPT who underwent parathyroidectomy. Clinical, biochemical, ultrasonographic and intraoperative data were evaluated. Results. There was a longer duration of parathyroidectomy in patients with AIT than in those without (113.3 min vs. 93.9 min, P=0.03). A lower rate of kidney stones was noted in patients with autoimmune thyroiditis (44.4% vs. 0%, P=0.03). Patients with AIT were more symptomatic, but this was not significant. There was no difference between the two groups in the prevalence of osteoporosis or thyroid nodular disease. Conclusions. A significantly longer duration of parathyroidectomy was seen in PHPT patients with AIT. Patients with PHPT undergoing surgery should be investigated for autoimmune thyroiditis, as this may affect surgical planning.

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.

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.

Do Symptoms and Serum Calcium Levels Affect the Results of Surgical Treatment of Primary Hyperparathyroidism?

Introduction

The purpose of this study was to investigate the difference in surgical outcomes between symptomatic and asymptomatic patients with primary hyperparathyroidism (PHPT) and between patients with high serum calcium and those with normal blood calcium, as well as to explore the epidemiological trend of PHPT in northern China.

Methods

Clinicopathologic data of 197 patients (50 men and 147 women) with PHPT who underwent surgery at the First Affiliated Hospital of Harbin Medical University from 2008 to 2017 were analyzed. Changes in clinicopathology were compared among different subgroups of patients. Patients were categorized into subgroups based on serum calcium levels, whether or not they presented with symptoms, and admission time.

Results

Of the total patients, 82.23% had hypercalcemic primary hyperparathyroidism (HCPHPT), 17.77% had normocalcemic primary hyperparathyroidism (NCPHPT), 45.18% had symptomatic primary hyperparathyroidism (SPHPT), and 54.82% had asymptomatic primary hyperparathyroidism (ASPHPT). Seventy-seven cases of PHPT involved thyroid nodules, with 22 confirmed as papillary thyroid carcinoma, and 29 confirmed as nodular goiter. There was no significant difference in the success rate of surgery, postoperative recurrence rate, and the symptoms of temporary hypocalcemia between the HCPHPT and NCPHPT groups, and between the SPHPT and ASPHPT groups. The incidence of PHPT has increased threefold since 2013.

Conclusions

Symptoms and serum calcium levels did not affect the results of surgical treatment for PHPT. The incidence of PHPT in northern China is increasing. Moreover, PHPT manifestation has shifted from the symptomatic to the asymptomatic form. Thyroid surgery should be performed in PHPT patients with thyroid nodules.

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.

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.

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.