Abstract:The incidence of true iT-PA is less than 1%, occurring in predictable locations. Thyroid lobectomy for a missing parathyroid adenoma is typically unsuccessful and should only rarely, if ever, be performed.
“…Different literatures have reported that the incidence rate of ETPA is 0.2% to 6.0%. [5–7] Cystic parathyroid adenomas take up 1% to 2% [4] of PHPT cases. Colsa-Gutiérrez et al [8] considered that cystic parathyroid adenomas could be caused by embryological remnants of the 3rd or 4th pharyngeal pouches and preservation of glandular secretion.…”
Rationale:
Cystic parathyroid adenomas are rare and seldom arise in ectopically located glands which may be found within the carotid sheath, mediastinum, thymus, or thyroid grand. They cannot be detected consistently by any imaging methods. Unusual symptoms may bring about certain pitfalls and difficulties for the diagnosis of primary hyperparathyroidism (PHPT) caused by cystic parathyroid adenomas. Until now, there are no specific guidelines on the management of cystic ectopic intrathyroidal parathyroid adenoma (ETPA).
Patient concerns:
An 82-year-old male musician presented abrupt thyroid enlargement, hoarseness, and trachea compression when he was playing the clarinet. Thyroid and renal function tests were normal. Serum-free calcium and parathyroid hormone (PTH) were in high concentration. Thyroid ultrasonography (US) detected a giant and cystic nodule within right thyroid lobe, which is the very image of cystic nodular goiter. Parathyroid US was negative. The cystic nodule had a decreasing radioactive uptake of Technetium-99m-methoxyisobutylisonitrile (
99m
Tc-MIBI). At patient's request, the invasive fine-needle aspiration (FNA) was not conducted.
Diagnoses:
The patient was initially diagnosed as cystic nodular goiter and inconclusive PHPT.
Interventions:
Enucleation of solitary cystic intrathyroidal nodule was conducted.
Outcomes:
The cystic nodule strongly resembled a nodular goiter grossly, but it was proved cystic ETPA by histopathology. Postoperative follow-ups found that serum-free calcium and PTH decreased sharply into normal range, and hoarseness and trachea displacement were obviously improved.
Lessons:
The diagnosis of cystic ETPA is easily overlooked for its rarity. Diagnostic pitfalls, including atypical symptoms, inconclusive imaging manifestation, and unidentified gross specimen, are highlighted. They make the diagnosis of PHPT caused by cystic ETPA challenging. Patients would rather choose surgical excision directly than invasive FNA. Acute hemorrhage of the preexisting ETPA may account for the cystic degeneration.
“…Different literatures have reported that the incidence rate of ETPA is 0.2% to 6.0%. [5–7] Cystic parathyroid adenomas take up 1% to 2% [4] of PHPT cases. Colsa-Gutiérrez et al [8] considered that cystic parathyroid adenomas could be caused by embryological remnants of the 3rd or 4th pharyngeal pouches and preservation of glandular secretion.…”
Rationale:
Cystic parathyroid adenomas are rare and seldom arise in ectopically located glands which may be found within the carotid sheath, mediastinum, thymus, or thyroid grand. They cannot be detected consistently by any imaging methods. Unusual symptoms may bring about certain pitfalls and difficulties for the diagnosis of primary hyperparathyroidism (PHPT) caused by cystic parathyroid adenomas. Until now, there are no specific guidelines on the management of cystic ectopic intrathyroidal parathyroid adenoma (ETPA).
Patient concerns:
An 82-year-old male musician presented abrupt thyroid enlargement, hoarseness, and trachea compression when he was playing the clarinet. Thyroid and renal function tests were normal. Serum-free calcium and parathyroid hormone (PTH) were in high concentration. Thyroid ultrasonography (US) detected a giant and cystic nodule within right thyroid lobe, which is the very image of cystic nodular goiter. Parathyroid US was negative. The cystic nodule had a decreasing radioactive uptake of Technetium-99m-methoxyisobutylisonitrile (
99m
Tc-MIBI). At patient's request, the invasive fine-needle aspiration (FNA) was not conducted.
Diagnoses:
The patient was initially diagnosed as cystic nodular goiter and inconclusive PHPT.
Interventions:
Enucleation of solitary cystic intrathyroidal nodule was conducted.
Outcomes:
The cystic nodule strongly resembled a nodular goiter grossly, but it was proved cystic ETPA by histopathology. Postoperative follow-ups found that serum-free calcium and PTH decreased sharply into normal range, and hoarseness and trachea displacement were obviously improved.
Lessons:
The diagnosis of cystic ETPA is easily overlooked for its rarity. Diagnostic pitfalls, including atypical symptoms, inconclusive imaging manifestation, and unidentified gross specimen, are highlighted. They make the diagnosis of PHPT caused by cystic ETPA challenging. Patients would rather choose surgical excision directly than invasive FNA. Acute hemorrhage of the preexisting ETPA may account for the cystic degeneration.
“…In addition, the evaluating radiologist should search for radiological manifestations of hyperparathyroidism, such as osteopenia, bone resorption, and brown tumours (Fig. 22 ) [ 55 , 56 ]. Fig.…”
Focal and diffuse thyroid abnormalities are commonly encountered during the interpretation of computed tomography (CT) exams performed for various clinical purposes. These findings can often lead to a diagnostic dilemma, as the CT reflects the nonspecific appearances. Ultrasound (US) examination has a superior spatial resolution and is considered the modality of choice for thyroid evaluation. Nevertheless, CT detects incidental thyroid nodules (ITNs) and plays an important role in the evaluation of thyroid cancer.In this pictorial review, we cover a wide spectrum of common and uncommon, incidental and non-incidental thyroid findings from CT scans. We also discuss the most common incidental thyroid findings, best practices for their evaluation, and recommendations for their management. In addition, we explore the role of imaging in the assessment of thyroid carcinoma (before and after treatment) and preoperative thyroid goiter, as well as localization of ectopic and congenital thyroid tissue.Teaching Points• Thyroid disorders tend to have non-specific CT appearances.• ITNs are common on neck CT.• ITN management depends on nodule size, age, health status, lymphadenopathy, and invasion.• CT is used in assessment of cancer extension, mass effect, invasion, and recurrence.• CT plays a role in preoperative planning in patients with symptomatic goiter.
“…As shown in postmortem studies, the incidence of the intra-thyroid location of the parathyroid glands was estimated at less than 0.2%, and 2–5% in PH patients (17) . The same rate was estimated as less than 1% in a retrospective study by Goodman including more than 10,000 patients (18) . Intrathyroidal adenomas are difficult to distinguish from lesions that are typically visualized on ultrasound in the course of thyroid goiter.…”
Primary hyperparathyroidism (PH) represents one of the most common endocrine diseases. In most cases, the disorder is caused by parathyroid adenomas. Bilateral neck exploration has been a widely used treatment method for adenomas since the 20's of the twentieth century. In the last decade, however, it has been increasingly replaced by a minimally invasive surgical treatment. Smaller extent, shorter duration and lower complication rate of such a procedure are emphasized. Its efficacy depends on a precise location of parathyroid tissue during the preoperative imaging. Scintigraphy and ultrasound play a major role in the diagnostic algorithms. The efficacy of both methods has been repeatedly verified and compared. The still-current guidelines of the European Association of Nuclear Medicine (2009) emphasize the complementary role of scintigraphy and ultrasonography in the preoperative diagnostics in patients with primary hyperparathyroidism. At the same time, attempts are made to improve both these techniques by implementing new study protocols or innovative technologies. Publications have emerged in the recent years in the field of ultrasonography, whose authors pointed out the usefulness of elastography and contrast media. Nuclear medicine studies, on the other hand, focus mainly on the assessment of new radiotracers used in the positron emission tomography (PET). The aim of this article is to present, based on literature data, the possibilities of ultrasound and scintigraphy in the preoperative diagnostics in patients with primary hyperparathyroidism. Furthermore, the main directions in the development of imaging techniques in PH patients were evaluated.
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