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Atypical Parathyroid Adenoma: A Diagnostic DilemmaT. Seth Tudor PGY3Freeman Health System Joplin, MOOklahoma State University
Learning Objectives: Parathyroid adenoma (PA) vs parathyroid carcinoma (PC) Clinical signs and symptoms Laboratory and radiological studies Intraoperative findings Histopathology Management
Case Presentation 05/23/13 J.C. 66 yo man hoarseness, SOBwE voice for one month Difficulty swallowing pills, and straining, can only whisper PMH- OA, DM2, HTN, CAD PSH- T&A, Coronary stenting 2005, vasectomy FH- OA, CAD, hypothyroidism SH- 20 year smoking history, ETOH once a month PE- No cervical LAD or mass Endoscopy- L paramedian TVC paralysis Plan- CT neck and chest with contrast
CT Results
CT Results
CT Results
Follow Up CT- L posterior inferior thyroid mass 36x20mm Hoarseness stable Upon questioning, had elevated serum Ca (11.5 on 05/01/11) Denied renal, bone, psychiatric symptoms TSH/FT4 WNL No sx of hypo/hyperthyroidism Plan- PTH, serum Ca and albumin, Sestamibi if indicated
Follow Up PTH 117.1, Ca 11 Sestamibi
Intraoperative findings L neck exploration with parathyroidectomy, thyroid lobectomy Pre/post op PTH- 146.1/104.8 (10.4 two hrs post op) 2x3cm fibrous gray capsule RLN encased within (sacrificed) Adherent to trachea, thyroid, esophagus Tissue lateral to trachea/esophagus resected en bloc Frozen section consistent w hypercellular PA
Histopathology Results Nodular growth of parathyroid tissue with hypercellularity Fibrotic bands surrounding capsule, but no parenchymal inv. Abuts but does not invade thyroid gland Fibrosis involving nerve tissue, but no perineural invasion Hemorrhage and necrosis in capsule, but no vascular inv. No cellular atypia or increased mitotic figures Fibrotic changes felt to be degenerative in nature, rather than
evidence of carcinoma Final Dx- Atypical parathyroid adenoma
Histological Findings
Histological Findings
Parathyroid CA
Parathyroid CA vs Adenoma Clinical findings
PC PA
Neck Mass Common (31-70%) Rare (<2%)Hoarseness Uncommon (1-14%) Rare (<<1%)Average Age 45-60 55-70Women : Men 0.58 3.12Renal Involvement* Common (32-80%) Rare (4-18%)Skeletal Involvement* Common (34-91%) Rare (<5%)Psychiatric Involvement Common RareRenal & Skeletal Disease Common RareAsymptomatic Rare (<5%) Common (>80%)
Parathyroid CA vs Adenoma Clinical findings
PC PA
Neck Mass Common (31-70%) Rare (<2%)Hoarseness Uncommon (1-14%) Rare (<<1%)Average Age 45-60 55-70Women : Men 0.58 3.12Renal Involvement* Common (32-80%) Rare (4-18%)Skeletal Involvement* Common (34-91%) Rare (<5%)Psychiatric Involvement Common RareRenal & Skeletal Disease Common RareAsymptomatic Rare (<5%) Common (>80%)
Parathyroid CA vs Adenoma Radiology and Laboratory findings
PC PATumor Size (p<0.01) 30.5±9.4mm 20.6±8.2mmTumor >30mm Frequent Rare (<<1%)Mean Total PTH (p<0.01) 693±1128.1 (97-4700) 125.86±83.5 (66-916)
Median Total PTH 212 95 Mean Total Ca (p<0.01) 14.08±2.86 (9.8-24) 11.19±0.68 (10.6-18.9)
Median Total Ca 14 11
Parathyroid CA vs Adenoma Radiology and Laboratory findings
PC PATumor Size (p<0.01) 30.5±9.4mm 20.6±8.2mmTumor >30mm Frequent Rare (<<1%)Mean Total PTH (p<0.01) 693±1128.1 (97-4700) 125.86±83.5 (66-916)
Median Total PTH 212 95 Mean Total Ca (p<0.01) 14.08±2.86 (9.8-24) 11.19±0.68 (10.6-18.9)
Median Total Ca 14 11
Parathyroid CA vs Adenoma Intraoperative findings
PC PA
Gross Texture Firm SoftGross Color Gray-White Brown-YellowCystic Component 21% Rare (undocumented?)Fibrosis Common RareRLN Involvement Uncommon RareMass (g) 2-10 <3
Parathyroid CA vs Adenoma Intraoperative findings
PC PA
Gross Texture Firm SoftGross Color Gray-White Brown-YellowCystic Component 21% Rare (undocumented?)Fibrosis Common RareRLN Involvement Uncommon RareMass (g) 2-10 <3
Parathyroid CA Histopathology Schantz and Castleman Criteria (1973) Fibrous bands forming trebecular architecture intersecting tumor Capsular invasion Vascular invasion Mitotic activity within tumor cells
Not exclusive to PC, may be found in atypical PA Frozen section is not able to reliably distinguish
Parathyroid CA vs Adenoma Management of PC En bloc resection of tumor Sacrifice of RLN* Central compartment neck dissection Close, frequent PTH and serum Ca follow up
Management of PA Exploration and excision of adenoma Spare surrounding tissue, as it is a benign process
Comprehensive Treatment Preop suspicion & intraoperative findings En bloc resection of tumor Initial resection is best chance of cure for PC If RLN involved in suspicious tumor, resection is appropriate Iacobone (2004) demonstrated RLN in 11/14 reoperations Lee (2009) spontaneous hemorrhage, abscess, cysts in PA may cause
neuropraxia/axonotmesis with good chance of recovery postop
Central neck dissection Ipsilateral thyroid lobectomy
Pitfalls Must recognize high risk clinical/laboratory scenarios Must recognize high risk intraoperative findings Incomplete resection on primary surgery Insufficient follow up
Questions/Discussion
References Wei, C., et al, 2012, Parathyroid Carcinoma: Update and Guidelines for Management, Current Treatment
Options in Oncology, 13:11-23. Iacobone, M., et al, 2004, Up-To-Date on Parathyroid Carcinoma: Analysis of an Experience of 19 cases,
Journal of Surgical Oncology, 88:223-228. Ricci, G., et al, 2012, Parathyroid Carcinoma: The Importance of High Clinical Suspicion for a Correct
Management, International Journal of Surgical Oncology. Shane, E., 2001, Parathyroid Carcinoma, The Journal of Clinical Endocrinology & Metabolism, 86:485-493. Okamoto, T., et al, 2009, Parathyroid Carcinoma: Etiology, Diagnosis, and Treatment, World Journal of
Surgery, 33:2243-2354 Schantz, A., Caslteman, B., 1972, Parathyroid Carcinoma: A Study of 70 Cases, Cancer, 31:600-605. Obara, T., Fuijimoto, Y., 1991, Diagnosis and Treatment of Patients with Parathyroid Carcinoma: An Update
and Review, World Journal of Surgery, 15:738-744. Schulte, KM., et al, 2012, Classification of Parathyroid Carcinoma, Annals of Surgical Oncology, 19:2620-2628. Givens, D., et al, 2012, Uncommon Presentation of Parathyroid Adenoma, Wiley Online Library, Head & Neck,
DOI 10.1002/hed.23124. Ng, SH., Lang, B., 2013, Parathyroid Carcinoma in a 30-year-old Man: A Diagnostic and management
challenge, World Journal of Surgical Oncology, 11:83. Lee, P., et al, 2007, Trends in the Incidence and Treatment of Parathyroid Carcinoma in the U.S., Cancer,
109:1736-1741. Clayman, G., et al, 2003, Parathyroid Carcinoma: Evaluation and Interdisciplinary Management, Cancer,
100:900-905. Lee, J., et al, 2009, Parathyroid Adenoma as a Cause of Vocal Fold Paralysis, Archives of Otolaryngology Head
and Neck Surgery, 135: 712-714.