Search Results (90)

Synchronous multiple parathyroid carcinoma is a rare condition within the already uncommon landscape of parathyroid malignancies, which comprise less than 1% of sporadic primary hyperparathyroidism cases. To date, only seven cases of synchronous multiple parathyroid carcinoma in sporadic primary hyperparathyroidism have been documented. This exceptional rarity complicates both the diagnostic process and therapeutic decision-making. Clinically, parathyroid carcinoma typically presents as a single mass determining severe symptoms. However, no single clinical, biochemical, or imaging feature allows for definitive preoperative diagnosis. Imaging modalities such as ultrasound and sestamibi scans exhibit variable sensitivity and may overlook multi-gland involvement. Histopathological examination remains the only reliable diagnostic method. Management strategies are also controversial: while some advocate for conservative surgery, en bloc resection is generally recommended for its association with improved local control and disease-free survival. Given the exceptional occurrence of synchronous multiple parathyroid carcinoma, there is a lack of standardized protocols for managing parathyroid carcinoma in cases of synchronous and multiple gland involvement. Early multidisciplinary evaluation and individualized treatment planning are therefore crucial. This review aims to synthesize the presently available knowledge about synchronous multiple parathyroid carcinoma, assist clinicians with the limited data available, and discuss the main challenges in the management of this rare entity. Full article

Primary hyperparathyroidism is commonly caused by parathyroid adenomas, hyperplasia, or, rarely, carcinoma. In up to 20% of cases, parathyroid tissue may be ectopic, often located in the mediastinum due to aberrant embryologic migration. Ectopic parathyroid glands pose a diagnostic and therapeutic challenge, and an accurate preoperative localization is essential for an effective and safe resection. Imaging modalities such as CT scan, TC-sestamibi scintigraphy, PET/CT, ultrasonography and MRI are routinely employed, whereas combined techniques offer improved diagnostic accuracy. Emerging approaches, however, including PET/CT with choline tracers, have shown promise in enhancing sensitivity in complex or recurrent cases. When ectopic glands are in the mediastinum, thoracic surgical intervention is required. Traditional open approaches, such as sternotomy or thoracotomy, are associated with significant morbidity. The development and evolution of minimally invasive surgery (MIS) has become the preferred approach in selected cases. When MIS is performed, intraoperative assessment and parathyroid identification are crucial to ensure complete gland removal. Intraoperative parathyroid hormone (ioPTH) monitoring provides real-time confirmation of surgical success. The integration of advanced imaging, intraoperative monitoring, and minimally invasive techniques significantly improves surgical outcomes while minimizing complications and accelerating patient recovery. Ultimately, the effective treatment of ectopic parathyroid glands relies on a personalized approach, adapting both diagnostic and surgical strategies to the unique anatomical and clinical context of each patient. Integration of advanced imaging, intraoperative monitoring, and minimally invasive techniques, combined with a multidisciplinary team involving endocrinologists, radiologists, and thoracic surgeons, is key to optimizing outcomes and reducing patient morbidity. Full article

Identifying parathyroid glands during surgery is challenging and time-consuming due to their small size (3–5 mm) and camouflaged appearance in the background of the thyroid, lymph nodes, fat, and other neck structures. For the gland itself, it is also important to differentiate abnormal ones from normal ones. Accidental damage or removal of the normal glands can result in complications like hypocalcemia, which may necessitate lifelong medication dependence, and, in extreme cases, lead to death. The study of autofluorescence optical properties of normal and abnormal parathyroid glands and the surrounding tissue will be helpful for developing non-invasive detection devices. The near-infrared (NIR) autofluorescence characteristics of parathyroid and thyroid tissues have been studied extensively and are now used for parathyroid gland detection during surgery. Additionally, there have been a few reports on the UV-visible light-excited autofluorescence characteristics of these tissues with a focus on spectroscopy. However, there is a lack of high-resolution, side-by-side autofluorescence imaging comparisons of both tissue types under various excitation wavelengths, ranging from visible to NIR. We developed a standalone tabletop autofluorescence imaging system to acquire images of ex vivo specimens in the operating room under different excitation wavelengths: visible 405 nm, 454 nm, 520 nm, 628 nm, and NIR 780 nm. Autofluorescence imaging features of parathyroid adenomas for each excitation wavelength were described and compared. It was found that visible light excites much stronger autofluorescence from parathyroid adenoma tissue compared to NIR light. However, NIR excitation provides the best intensity difference/contrast between parathyroid adenoma and thyroid tissue, making it optimal for differentiating these two tissue types, and detecting parathyroid adenoma during surgery. The high fluorescent site under the NIR 780 nm excitation also generates high fluorescence under visible excitation wavelengths. Heterogeneous fluorescence patterns were observed in most of the parathyroid adenoma cases across all the excitation wavelengths. Full article

Background: Parathyroid neoplasia is a heterogeneous group of tumors, including parathyroid adenoma (PA), atypical parathyroid tumors (aPTs), and parathyroid carcinoma (PC). Differential diagnosis, especially preoperatively, between parathyroid carcinoma and the other two entities is challenging. The purposes of this study were to highlight the main differences between different parathyroid tumors and to evaluate how combined PC suspicion and intraoperative adjuncts can influence surgical decision-making and outcome-related issues. Methods: We performed a retrospective study of a database of patients diagnosed with parathyroid tumors who underwent surgical treatment at our endocrine surgery referral center between June 2019 and July 2024. Demographic, clinical, biochemical, imaging, intraoperative, immunohistochemical, and follow-up data were analyzed. Results: A total of 83 cases were included in our study, divided for analysis into PA (n = 67), aPT (n = 9) and PC (n = 7) subgroups. The clinical profile of the cohort showed a significant difference (p < 0.05) between the PA, aPT, and PC subgroups regarding the presence of palpable tumors (0% vs. 11.11% vs. 14.29%), both bone and kidney involvement (14.93% vs. 44.44% vs. 85.71%), and extensive disease beyond bone and kidney involvement (4.48% vs. 44.44% vs. 71.43%). PTH levels over five times the normal value were present at significantly different rates (p < 0.001), with higher rates in the aPT and PC subgroups (55.56% and 85.71%, respectively) compared with the PA subgroup (7.46%). Also, a significant difference (p < 0.001) was observed when analyzing extreme albumin-corrected serum calcium elevations over 14 mg/dL, with much higher rates in the PC subgroup (71.43%) compared to PA (1.49%) and aPT (33.33%). On preoperative ultrasonography, a significantly higher number of PCs presented diameters ≥ 3 cm (p < 0.001), depth-to-width ratios (D/W) ≥ 1 (p = 0.003), suspicious delineation (p < 0.001), and suspicious echotexture features (p < 0.001), compared to PAs. On preoperative US performed by the surgeon, suspicious features for thyroid cancer were identified in five more patients compared to the four identified by the initial US evaluation, and all (10.84% of all patients) were confirmed on final histopathology as papillary thyroid cancers. Intraoperatively, a significant difference (p < 0.001) regarding parathyroid macroscopic suspicious features, including adhesions to the thyroid gland, was seen between subgroups. When analyzing only cases with en bloc resection, we found that, in all PC cases, a combined preoperative suspicion was present, and in five cases an intraoperative suspicion was raised. Immunohistochemical data showed significantly different median Ki-67 indices between subgroups (1, 2, and 5; p = 0.008) and a different parafibromin staining profile between PC and aPT. Regarding intraoperative neuromonitoring use, a significantly lower incidence of voice changes related to the external branch of the superior laryngeal nerve was observed in the monitoring vs. non-monitoring group (57.14% vs. 12.5%, p = 0.019). Conclusions: Our findings confirm that, in a multimodal and combined diagnostic approach, early pre- and intraoperative PC suspicion can be raised in order to optimize surgical treatment and, thus, favorably influence the outcome. Utilizing all resources available, including intraoperative parathormone determination, laryngeal nerve neuromonitoring, and immunohistochemistry staining, can bring extra benefit to the management of these challenging cases. Full article

A 49-year-old female presented for nuclear medicine diagnostics of a sonographically suspected parathyroid adenoma dorsal to the cranial pole of the right thyroid lobe. The patient received Tc-99m-pertechnetate and Tc-99m-sestamibi (including SPECT/CT) scans, revealing no sestamibi uptake by the suspected parathyroid adenoma but a ventrally adjacent autonomous thyroid adenoma. Additional F-18-ethylcholine-PET/CT as well as subsequent Tc-99m-sestamibi-SPECT/US and F-18-ethylcholine-PET/US fusion imaging confirmed the suspected diagnosis of simultaneous autonomous thyroid adenoma and parathyroid adenoma. A blood analysis showed additional Graves’ disease. Full article

The clinicopathological and molecular features of synchronous parathyroid carcinoma (PC) and thyroid carcinoma in a male patient are presented. At 11, he received mantle field radiotherapy for Hodgkin lymphoma. He had a 26-year adulthood history of recurrent nephrolithiasis treated five times with lithotripsy. At 52, he was referred to our clinic for hypercalcemia. Primary hyperparathyroidism was diagnosed (calcium: 3.46 mmol/L, parathormone: 150 pmol/L, preserved renal function, nephrolithiasis, and osteoporosis). Neck ultrasound revealed a 41 × 31 × 37 mm nodule in the left thyroid and smaller nodules in the right thyroid. Enlarged cervical lymph nodes were not observed. The large nodule was interpreted as parathyroid adenoma on 99Tc-pertechnetate scintigraphy/99Tc-MIBI scintigraphy with SPECT/CT. Total left-sided and subtotal right-sided thyroidectomy were performed. Histopathology confirmed locally invasive, low-grade PC (pT2; positive for parafibromin and E-cadherin, negative for galectin-3 and PGP9.5; wild-type expression for p53 and retinoblastoma protein; Ki-67 index 10%) and incidental papillary thyroid carcinoma (pT1b). Genetic profiling revealed no loss in CDC73, MEN1, CCND1, PIK3CA, CDH1, RB1, and TP53 genes. Deletions in CDKN2A, LATS1, ARID1A, ARID1B, RAD54L, and MUTYH genes and monosomies in nine chromosomes were identified. The tumor mutational burden and genomic instability score were low, and the tumor was microsatellite-stable. The thyroid carcinoma exhibited a TRIM24::BRAF fusion. Following surgery, the parathormone and calcium levels had normalized, and the patient underwent radioiodine treatment for thyroid cancer. The follow-up of 14 months was eventless. In summary, the clinical, laboratory, and imaging features of hyperparathyroidism taken together could have suggested malignancy, then confirmed histologically. The synchronous carcinomas were most likely caused by irradiation treatment diagnosed 41 years after exposure. It seems that the radiation injury initially induced parathyroid adenoma in young adulthood, which underwent a malignant transformation around age fifty. Full article

Multiple endocrine neoplasia type 1 (MEN-1) is an autosomal dominant inherited syndrome characterized by a genetic predisposition for the development of specific hormone-secreting tumors. Effective diagnosis and management of MEN-1 require genetic testing, regular surveillance, and imaging follow-up to detect and monitor tumor growth or recurrence and to plan for surgical intervention. The aim of this narrative review is to provide an overview of the current imaging modalities and their role in the diagnosis and follow-up of patients affected by MEN-1, focusing on the detection and characterization of associated neoplasms. The knowledge of the most frequent MEN-1 associated neoplasms and their imaging features is crucial for an accurate diagnosis, management, and treatment. Full article

Background/Objectives: Primary hyperparathyroidism (PHPT) is a prevalent endocrine disorder, with ectopic mediastinal parathyroid adenomas accounting for up to 30% of cases, posing significant diagnostic and surgical challenges. While traditional management relies on invasive procedures, minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) have emerged as viable alternatives. This study addresses a gap in the current literature by presenting our experience with VATS for mediastinal ectopic parathyroid adenomas, particularly in underreported retrotracheal/paraesophageal locations. By integrating a retrospective case series with a systematic literature review, we highlight evolving surgical strategies and their implications for patient outcomes in anatomically complex cases. Methods: A retrospective analysis was conducted over a three-year period on patients diagnosed with mediastinal ectopic parathyroid adenomas. Data on demographic characteristics, preoperative imaging, surgical techniques, intraoperative findings, and postoperative outcomes were collected. This study primarily compared the outcomes of VATS with those of traditional thoracotomy, with a focus on surgical success, complication rates, and length of hospital stay. Results: Six patients underwent surgical resection for mediastinal ectopic parathyroid adenomas (two intrahymic and four retrotracheal/paraesophgeal). VATS was the preferred approach in all cases, with one patient requiring conversion to thoracotomy due to challenging vascular anatomy. Surgical success, defined as the normalization of postoperative serum calcium levels, was achieved in all cases. The median operative time was 80 min, and the mean hospital stay was 6.25 days. One patient developed transient postoperative hypocalcemia, necessitating supplementation. No major surgical complications were observed. Conclusions: This study supports VATS as a safe and effective approach for mediastinal ectopic parathyroid adenoma resection, offering reduced morbidity and shorter recovery times compared to traditional open surgery. The findings align with emerging evidence advocating for minimally invasive techniques in complex mediastinal surgeries. Full article

Background: Autofluorescence can identify parathyroid glands and protect their vasculature during thyroid surgery to prevent postoperative hypoparathyroidism. This study evaluates the Burjeel intraoperative protocol using near-infrared indocyanine green (ICG-NiR) imaging to preserve parathyroid glands during total thyroidectomy. Methods: This study conducted a single-centre retrospective matched cohort analysis involving 156 consecutive patients who underwent thyroidectomy using the Burjeel ICG-guided near-infrared (NiR) fluorescence protocol (“ICG group”). Patients were matched 1:1 based on gender and extent of resection with 156 counterparts who underwent standard thyroid surgery. The Stryker Spy-phi NiR fluorescence imaging system (Stryker™, Portage, MI, USA) was utilized in three modes—green, black/white, and colourful—to facilitate real-time visualization. Post-lobectomy, each parathyroid gland was individually scored for viability before the closure of the surgical site. Patients were stratified into hypoparathyroidism and euparathyroidism groups based on the parathyroid hormone levels measured on the first postoperative day. Results: The groups had 133 women and 23 men. Preoperative factors like age (43.7 years in both groups); resection time (49 min in the ICG group versus 50 min in the conventional group); and PTH, TPO, and Vit D3 levels were not statistically different. The ICG group had a lower rate of inadvertent parathyroidectomy (9% vs. 17.9% in the standard group, chi-square test, p = 0.015), a lower rate of postoperative hypoparathyroidism (18.6% vs. 35.3%, chi-square test, p = 0.001), and higher postoperative PTH levels (t-test, p = 0.0001). Postoperative hypoparathyroidism was associated with malignant surgical pathology and malignancy on both sides (p = 0.026 and 0.01, respectively). This study found that female participants had a higher incidence of unintentional parathyroidectomy (p = 0.001) but not postoperative hypoparathyroidism. Subgroup analysis showed a negative connection between ICG score and female hypoparathyroidism. Conclusions: The new Burjeel ICG-guided NiR fluorescence approach has greatly reduced inadvertent parathyroidectomy and hypoparathyroidism in female total thyroidectomy patients. Further research is needed to identify numerical variables that aid intraoperative decision-making. Full article

Background/Objectives: Parathyroidectomy is a curative procedure for primary hyperparathyroidism, and multi-phase CT is an integral part of surgical planning. While patients may be referred to centers specializing in endocrine surgery, their imaging may be performed at other facilities without the same high-volume expertise. Methods: A retrospective review was performed of radiologist second reads of outside neck CT imaging in patients with hyperparathyroidism referred for surgical management. Results: The initial outside report was 59% sensitive for localization of parathyroid adenoma in the 74 patients with surgical pathologic confirmation. Second reads of the same CT scans correctly identified the parathyroid adenoma in an additional 24% of patients, for a total sensitivity of 83%. For the 23% of patients with pathologically confirmed multi-gland involvement, the initial outside report was 21% sensitive for lesion detection, and the second read of the same scans was 68% sensitive. Conclusions: Endocrine surgeons should be aware that community-based radiology interpretation of neck CT may be less sensitive than reported series from academic and high-volume practices. In the present study, interpretation via second read of outside CT scans by a neuroradiologist engaged with the endocrine surgery service line increased the sensitivity of detecting candidate lesions, both for single-gland and multi-gland involvement. While it is preferred to have preoperative imaging and interpretation within the same high-volume center as the surgeon for consistency of imaging quality, experience and communication, radiologist second reads deserve financial and service line support when that is not possible given the impact on surgical planning and patient care. Full article

Background: Parathyroid cancers are rare endocrine malignancies that pose diagnostic and therapeutic challenges, particularly when discovered incidentally or in the presence of multiple endocrine disorders. This study aims to provide clinical, biochemical and pathological insights into these malignancies through a retrospective case series. Methods: We analyzed retrospectively, from a tertiary and an endocrine surgery referral center, 13 cases of parathyroid cancers, where 4 cases were associated with thyroid cancers, including demographic data, clinical presentation, biochemical markers, imaging, surgical interventions, histopathological findings and follow-up outcomes. Descriptive statistics were used to summarize patient characteristics. Results: The median age of the cohort was 64 (range: 40–81 years), with a female-to-male ratio of 8:5. More than half of the cases (61.53%) were diagnosed incidentally, with common biochemical findings including elevated parathyroid hormone (PTH) levels (median: 430 pg/mL) and hypercalcemia in 80% of the patients. All patients underwent surgery, with parathyroid resections with concomitant total thyroidectomy (62%) or lobectomy (23%) as the most common interventions. Histopathological analysis confirmed parathyroid carcinoma in all cases, with coexisting thyroid malignancies observed in 31%. An immunohistochemical profile performed in about half of the patients was in accordance with previously published data. Postoperative normalization of PTH levels was achieved in 77% of patients, and no recurrence or metastasis was observed in 85% of cases during follow-up. Conclusions: Despite the exceptional rarity of the disease, this case series highlights the importance of preoperative biochemical and imaging evaluation and the efficacy of surgical management. Long-term outcomes remain favorable with early diagnosis and diligent postoperative monitoring. Further research into molecular biomarkers and targeted therapies is warranted to improve the management of advanced or recurrent disease. Full article

Background/Objectives: Brown tumors are rare bone lesions associated with hyperparathyroidism, particularly secondary hyperparathyroidism (SHPT), in chronic renal failure. While brown tumors commonly affect bones rich in marrow, the involvement of the sphenoid sinus is extremely rare and can present with neurological symptoms. This study reports a case of a sphenoid sinus brown tumor in a patient on hemodialysis, highlighting its clinical presentation and diagnostic challenges. Methods: A 31-year-old woman undergoing chronic hemodialysis presented with a severe headache, diplopia, and progressive vision loss in her left eye. Laboratory tests revealed hypercalcemia, hypophosphatemia, and elevated parathyroid hormone (PTH) levels, consistent with SHPT. The diagnosis was confirmed through a clinical examination and magnetic resonance imaging (MRI). Results: The clinical examination confirmed decreased visual acuity in the left eye. The laboratory results revealed serum calcium of 15.5 mg/dL, phosphate of 1.0 mg/dL, and PTH of 2000 pg/mL, consistent with SHPT. The imaging studies identified a brown tumor in the sphenoid sinus exerting a mass effect on adjacent structures. This case underscores the rarity of brown tumors in this location, with very few similar reports in the literature. Conclusions: Although rare, brown tumors should be considered in patients with SHPT who present with neurological symptoms or cranial lesions. An early diagnosis through biochemical and imaging studies is crucial to prevent severe complications. The management involves treating the underlying hyperparathyroidism, with surgical intervention indicated in cases of neural compression. Full article

Background: Uremic tumoral calcinosis (UTC) is a rare yet severe complication of chronic kidney disease (CKD), predominantly occurring in patients undergoing renal replacement therapy (RRT). It is characterized by extensive soft tissue calcifications, frequently associated with chronic hyperphosphatemia and disruptions to calcium–phosphorus metabolism. Case report: This report describes a 34-year-old woman with end-stage renal disease (ESRD) secondary to lupus nephritis, undergoing continuous ambulatory peritoneal dialysis (CAPD). She presented with a progressively enlarging calcified mass in the proximal phalanx of the third finger on her right hand, accompanied by functional impairment. Laboratory findings revealed persistent hyperphosphatemia (8.8 mg/dL), elevated parathyroid hormone levels (901 pg/mL), and low vitamin D levels (9 ng/mL), indicating significant disturbances to mineral metabolism. Imaging studies, including X-ray and whole-body 18F-Choline positron emission tomography/computed tomography (PET/CT), confirmed the presence of localized calcifications in the soft tissue of the proximal phalanx of the third finger on her right hand and parathyroid hyperplasia, respectively. Initial management included the optimization of phosphate binders and calcimimetic therapy, with the subsequent intensification of dialysis therapy. Transitioning to automated peritoneal dialysis (APD) with high-volume exchanges resulted in a notable improvement in biochemical parameters and the eventual remission of the calcified mass. Conclusion: This case underscores the importance of comprehensive management in dialysis patients, including dietary phosphate restriction, the appropriate use of non-calcium-based binders, and tailored dialysis regimens to prevent and treat CKD-related mineral and bone disorders. It also highlights the utility of imaging modalities such as PET/CT in diagnosing UTC and monitoring response to therapy. Further research is needed to elucidate the pathophysiology of UTC and optimize its management in dialysis patients. Full article

Patients diagnosed with multiple endocrine neoplasia type-1 (MEN1) often initially present with primary hyperparathyroidism (pHPT), and typically undergo surgical intervention. While laboratory tests are fundamental for diagnosis, imaging is crucial for localizing pathological parathyroids to aid in precise surgical planning. In this pictorial review, we will begin by comprehensively examining key imaging techniques and their established protocols, evaluating their effectiveness in detecting abnormal parathyroid glands. This analysis will emphasize both the advantages and potential limitations within the clinical context of MEN1 patients. Additionally, we will explore integrated imaging approaches that combine multiple modalities to enhance localization accuracy and optimize surgical planning—an essential component of holistic management in MEN1 cases. Various imaging techniques are employed for presurgical localization, including ultrasound (US), multiphase parathyroid computed tomography (CT) scanning (4D CT), magnetic resonance imaging (MRI), and nuclear medicine techniques like single photon emission computed tomography/CT (SPECT/CT) and positron emission tomography/CT (PET/CT). US is non-invasive, readily available, and provides high spatial resolution. However, it is operator-dependent and may have limitations in certain cases, such as intrathyroidal locations, the presence of bulky goiters, thyroid nodules, and previous thyroidectomy. Four-dimensional CT offers dynamic imaging, aiding in the identification of enlarged parathyroid glands, particularly in cases of ectopic or supernumerary glands. Despite concerns about radiation exposure, efforts are underway to optimize protocols and reduce doses, including the use of dual-energy CT. MR imaging offers excellent soft tissue contrast without radiation exposure, potentially providing superior differentiation between parathyroid glands and the surrounding structures. Radionuclide imaging, especially PET/CT using radiopharmaceuticals like [¹⁸F]FCH, shows promising results in localizing parathyroid tumors, particularly in patients with MEN1. [¹⁸F]FCH PET/CT demonstrates high sensitivity and may provide additional information compared to other imaging modalities, especially in cases of recurrent HPT. Full article

Parathyroid carcinoma (PC) is a rare endocrine malignancy that poses significant diagnostic challenges due to its resemblance to benign conditions. This case series describes the clinical presentation, diagnosis, management, and short-term outcomes of four male patients (aged 54, 65, 73, and 74 years) with primary hyperparathyroidism and hypercalcemia. The preoperative diagnosis of PC remains challenging; suspicion should arise in cases of severe hypercalcemia, elevated parathyroid hormone levels, and the presence of a mass on imaging or during surgery. All patients underwent an initial localized parathyroidectomy, with PC confirmed postoperatively. Subsequently, they received ipsilateral hemithyroidectomy and prophylactic central lymph node dissection. Over a two-year follow-up period, all patients maintained normocalcemia without evidence of disease recurrence or metastasis. In conclusion, whether to perform a complete en bloc resection or a two-step surgical strategy remains a difficult decision in PC patients with intricate preoperative evaluations. Full article