Table of Contents  
CASE SERIES
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 495-498  

Parathyroid adenomas: A case series and clinicopathological study from a tertiary care center in South India


1 Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
4 Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
5 Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication12-Jul-2016

Correspondence Address:
Amitabh Jena
Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.186072

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  Abstract 


Background: The incidence of primary hyperparathyroidism (PHP) in India is 2.5/1000 individuals. The major cause for PHP is parathyroid adenoma. To arrive at the correct diagnosis, clinical setting, biochemical and radiological investigations, the status of other glands assessed intraoperatively and finally histopathologic confirmation is essential. Materials and Methods: We carried out a retrospective analysis of the last 5 years of operated cases of parathyroid adenomas. Diagnosis was based on histological confirmation. In all the cases clinical data, details of biochemical, radiological, and other investigations including histopathological findings were recorded. Results: There were four operated patients of parathyroid adenoma at our center in the last 5 years. Out of four operated cases of parathyroid adenomas, three were symptomatic and one case was detected incidentally. The symptoms were varied and included skeletal, renal, neuromuscular, and neuropsychiatric manifestations. Two of the patients had diabetes mellitus at the time of presentation. They showed improvement in glycemic control after surgery. Histopathologically, all the parathyroid adenomas were of clear cell type without any evidence of capsular or vascular invasion to suggest the possibility of malignancy. Conclusion: Majority of our patients were females who showed symptomatic improvement after surgery. Histopathologically, all the cases were parathyroid adenomas and in one case of papillary carcinoma of thyroid, the parathyroid adenoma was incidentally detected.

Keywords: Hyperparathyroidism, papillary carcinoma of thyroid, parathyroid adenoma


How to cite this article:
Jena A, Patnayak R, Suresh V, Kalawat TC, Phaneendra BV, Lakshmi AY, Sachan A. Parathyroid adenomas: A case series and clinicopathological study from a tertiary care center in South India. Med J DY Patil Univ 2016;9:495-8

How to cite this URL:
Jena A, Patnayak R, Suresh V, Kalawat TC, Phaneendra BV, Lakshmi AY, Sachan A. Parathyroid adenomas: A case series and clinicopathological study from a tertiary care center in South India. Med J DY Patil Univ [serial online] 2016 [cited 2022 Oct 5];9:495-8. Available from: https://www.mjdrdypu.org/text.asp?2016/9/4/495/186072




  Introduction Top


Parathyroid adenoma is the most common cause for primary hyperparathyroidism (PHP).[1],[2] The correct diagnosis is often arrived at by taking into account the pathologic findings, clinical settings, biochemical and radiological investigations, and the status of other glands assessed intraoperatively. There has been prior Indian data regarding parathyroid pathology from different parts of the country.[3],[4],[5],[6],[7] In this study of 5 years, we have analyzed our data of operated parathyroid adenoma in a tertiary health care center in South India.


  Materials and Methods Top


This is a retrospective analysis of parathyroid adenomas, operated in the Department of Surgical Oncology at a tertiary care center over a 5-year period (January 2008-December 2012). Clinical data and details of biochemical, radiological and other investigations were obtained from the medical records. Histopathological findings were assessed from the Department of Pathology records using the hospital information system.


  Results Top


During the study period, there were four cases of operated parathyroid adenoma. One of them was an incidentally detected parathyroid adenoma operated along with papillary carcinoma of the thyroid. One case of parathyroid adenoma with associated diabetes mellitus was previously reported from our institute.[6] Three of the cases of parathyroid adenoma were symptomatic at presentation whereas one was asymptomatic in nature. This asymptomatic case was actually operated for papillary carcinoma of the thyroid. The symptoms were varied and included skeletal, renal, neuromuscular, and neuropsychiatric manifestations.

Two patients (i.e., patients 1 and 2) were detected to have diabetes at the time of presentation.[6] In patient number-2, there was associated distal renal tubular acidosis. The biochemical findings revealed hypercalcemia and increased parathyroid hormone level in all the symptomatic patients (i.e., patients 1-3). Ultrasound of abdomen revealed the presence of bilateral renal stones in patient 2. Ultrasonogram of the neck was done for all cases which revealed a single parathyroid gland enlargement in patients 1, 2, and 3. The fourth patient in our series presented with thyroid swelling for the last 7 years which was increasing in size for 6 months. The ultrasonography was reported as nodular lesions in both lobes of the thyroid. The Fine needle cytology was reported as suspicious of papillary carcinoma of thyroid. Later on, histopathological examination revealed papillary carcinoma in the isthmic region of thyroid. The specimen submitted as left paratracheal lymph node showed features of parathyroid adenoma. In the postoperative period, the patient maintained normal levels of serum calcium and phosphorus.

Technetium-99m methoxyisobutylisonitrile (99m Tc MIBI) scintigraphy was done in all the symptomatic cases, which picked up a single parathyroid adenoma [Figure 1]. In all these cases, right-sided parathyroid was involved. Parathyroidectomy was done in all patients as they were symptomatic. During surgery, all the four glands were assessed and care was taken to preserve the recurrent laryngeal nerve [Figure 2].
Figure 1: Technetium-99m methoxyisobutylisonitrile dual phase parathyroid scintigraphy, anterior neck images. (a) Initial 15 min image and (b) 90 min images show increased radiotracer concentration in the right inferior parathyroid adenoma

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Figure 2: Intraoperative picture showing right inferior parathyroid adenoma

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The gross weight of operated glands varied from 300 mg to 1 g. Histopathology of all the parathyroid adenomas revealed the presence of capsulated mass adjacent to normal parathyroid tissue. Parathyroid adenomas were predominantly of the clear cell type. There was no evidence of either capsular or vascular invasion in any patient, to suggest the possibility of malignancy [Figure 3].
Figure 3: Microscopy of parathyroid adenoma with capsule and adjacent normal parathyroid (H and E, ×100)

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The postoperative period for all these patients was uneventful. There was definitive symptomatic improvement after parathyroidectomy.


  Discussion Top


The incidence of PHP is 2.5/1000 individuals as reported in various articles from India.[5],[7],[8] Most studies have reported female preponderance as observed in our study.[9],[10] The age range of our patients was from 40 to 74 years. In one study from India, most of the patients were <45 years of age.[9]

Majority of PHP cases present as adenoma (85%) followed by hyperplasia and carcinoma.[1],[11] The symptomatic forms of PHP are more common in India, whereas in developed countries, the asymptomatic form is more commonly encountered.[12] In India, patients present at an advanced stage of PHP and with associated Vitamin D deficiency.[8] Three of our cases presented with classic clinical and biochemical manifestations of hyperparathyroidism whereas in one case, the parathyroid adenoma was incidentally detected. The symptoms were varied including skeletal, renal, neuromuscular, and neuropsychiatric manifestations.

In a study from India, the authors have analyzed 47 cases of PHP, out of which 42 were parathyroid adenomas and one was an atypical adenoma.[9]

There are a few case reports available in the literature regarding the presence of synchronous papillary carcinoma of thyroid and parathyroid adenoma.[13],[14],[15],[16],[17]

Synchronous medullary thyroid cancer and PHP is common in multiple endocrine neoplasia-2A (Sipple syndrome). In contrast, concomitant nonmedullary thyroid cancer and PHP is very rare accounting for only 1-2%. The coexistence of nonmedullary thyroid cancer is found in 2.4-3.7% of the patients operated on for PHP, in published studies. Previous neck irradiation and positive familial history are usually the two risk factors for both thyroid malignancies and parathyroid adenoma.[15]

One of our patients (patient 4) presented with thyroid swelling for the last 6 months which was increasing gradually. He was operated for the thyroid swelling which on postoperative histopathological examination showed papillary carcinoma of thyroid and the parathyroid adenoma. Parathyroid adenoma was incidentally detected and there was no feature of hyperparathyroidism. There are published articles which described patients with the presence of PHP and coexistence of thyroid carcinoma and parathyroid adenoma. One article even described the coexistence of double parathyroid adenoma, papillary carcinoma and follicular adenoma of the thyroid.[9] However, these patients had features of hyperparathyroidism, unlike our patient who did not exhibit any feature pertaining to hyperparathyroidism. One such similar type of presentation was previously described by Sakata et al. in their article.[13]

Two of the patients presented with diabetes mellitus and associated hyperparathyroidism. This association has been described in literature. After parathyroidectomy, these patients showed improvement in their glycemic control.[10]

Usually, hyperparathyroidism is associated with proximal tubular acidosis. In one of our cases, there was an uncommon association with distal tubular acidosis. In the literature few such cases have been described.[18]

Symptomatic PHP patients show improvement of cardiac and vascular functions after parathyroidectomy. Authors have described parathyroidectomy as an efficient and safe operation with excellent normalization of serum calcium and parathyroid hormone and a high rate of patient satisfaction.[19] Pradeep et al. in their series of PHP opined that in India, PHP presents at an advanced stage and is associated with Vitamin D deficiency which delays bone recovery after the operation.[20]

All of our patients showed significant improvement after surgery.


  Conclusion Top


We have noted the association of diabetes in two patients and that of distal tubular acidosis in one patient. There was even one incidental case of asymptomatic parathyroid adenoma. In all these cases, there was high clinical suspicion which was aided by biochemical findings and was followed by 99m Tc MIBI scintigraphy.99m Tc MIBI scintigraphy helped in confirming the diagnosis of parathyroid adenoma which was subsequently proved by histopathological examination. There was definitive indication for surgery in all these cases, and symptomatic improvement was noted after the surgery was performed.

The major limitation of this study was the small number of parathyroid adenomas as compared to other Indian studies. Prospective studies, from India, recruiting a larger number of patients are required to draw conclusions about the variations in clinical presentation and outcomes of surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
AACE/AAES Task Force on Primary Hyperparathyroidism. The American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons position statement on the diagnosis and management of primary hyperparathyroidism. Endocr Pract 2005;11:49-54.  Back to cited text no. 1
[PUBMED]    
2.
Sathe PA, Madiwale CV, Kandalkar BM, Bandgar TR, Shah NS, Menon PS. Primary hyperparathyroidism: A clinicopathological experience. Indian J Pathol Microbiol 2009;52:313-20.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Soin AS, Gupta S, Kochupillai N, Sharma LK. Primary hyperparathyroidism — An Indian study. Indian J Cancer 1994;31:72-7.  Back to cited text no. 3
[PUBMED]    
4.
Shrikande SS, Talvalkar GV. Parathyroid tumors: A study of 10 cases. Indian J Cancer 1980;17:164-8.  Back to cited text no. 4
    
5.
Fanthome B, Bhardwaj JR, Suryanarayana KM. Parathyroid neoplasms: The army hospital (research and referral) experience. Med J Armed Forces India 2006;62:312-5.  Back to cited text no. 5
    
6.
Agarwal G, Prasad KK, Kar DK, Krishnani N, Pandey R, Mishra SK. Indian primary hyperparathyroidism patients with parathyroid carcinoma do not differ in clinicoinvestigative characteristics from those with benign parathyroid pathology. World J Surg 2006;30:732-42.  Back to cited text no. 6
    
7.
Gopal RA, Acharya SV, Bandgar T, Menon PS, Dalvi AN, Shah NS. Clinical profile of primary hyperparathyroidism from western India: A single center experience. J Postgrad Med 2010;56:79-84.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Pradeep PV, Jayashree B, Mishra A, Mishra SK. Systematic review of primary hyperparathyroidism in India: The past, present, and the future trends. Int J Endocrinol 2011;2011:921814.  Back to cited text no. 8
    
9.
Maskey R, Panchani R, Varma T, Goyal A. Primary hyperparathyroidism in India: A cocktail of contemporary and classical presentations: Lesson from 47 cases. Indian J Endocrinol Metab 2013;17 Suppl 1:S209-11.  Back to cited text no. 9
    
10.
Gerl H, Pirlich M, Lochs H. Improvement of diabetes mellitus after excision of a parathyroid adenoma. Wien Klin Wochenschr 1998;110:841-4.  Back to cited text no. 10
    
11.
Carlson D. Parathyroid pathology: Hyperparathyroidism and parathyroid tumors. Arch Pathol Lab Med 2010;134:1639-44.  Back to cited text no. 11
    
12.
Mishra SK, Agarwal G, Kar DK, Gupta SK, Mithal A, Rastad J. Unique clinical characteristics of primary hyperparathyroidism in India. Br J Surg 2001;88:708-14.  Back to cited text no. 12
    
13.
Sakata S, Fuwa Y, Komaki T, Tarao M, Takuno H, Miura K. A case of papillary carcinoma of the thyroid associated with parathyroid adenoma without hyperparathyroidism. Intern Med 1992;31:459-62.  Back to cited text no. 13
    
14.
Meshikhes AW, Butt SA, Al-Saihati BA. Combined parathyroid adenoma and an occult papillary carcinoma. Saudi Med J 2004;25:1707-10.  Back to cited text no. 14
    
15.
Mahmoodzadeh H, Harirchi I, Hassan Esfehani M, Alibakhshi A. Papillary thyroid carcinoma associated with parathyroid adenoma. Acta Med Iran 2012;50:353-4.  Back to cited text no. 15
    
16.
Iakovou IP, Konstantinidis IE, Chrisoulidou AI, Doumas AS. Synchronous parathyroid adenoma and thyroid papillary carcinoma: A case report. Cases J 2009;2:9121.  Back to cited text no. 16
    
17.
Javadi H, Jallalat S, Farrokhi S, Semnani S, Mogharrabi M, Riazi A, et al. Concurrent papillary thyroid cancer and parathyroid adenoma as a rare condition: A case report. Nucl Med Rev Cent East Eur 2012;15:153-5.  Back to cited text no. 17
    
18.
Muthukrishnan J, Hari Kumar KV, Jha R, Jha S, Modi KD. Distal renal tubular acidosis due to primary hyperparathyroidism. Endocr Pract 2008;14:1133-6.  Back to cited text no. 18
    
19.
Agarwal G, Nanda G, Kapoor A, Singh KR, Chand G, Mishra A, et al. Cardiovascular dysfunction in symptomatic primary hyperparathyroidism and its reversal after curative parathyroidectomy: Results of a prospective case control study. Surgery 2013;154:1394-403.  Back to cited text no. 19
    
20.
Pradeep PV, Mishra A, Agarwal G, Agarwal A, Verma AK, Mishra SK. Long-term outcome after parathyroidectomy in patients with advanced primary hyperparathyroidism and associated vitamin D deficiency. World J Surg 2008;32:829-35.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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