Cytopathologist-Performed Ultrasound-Guided Fine-Needle Aspiration of Parathyroid Lesions

ArticleinDiagnostic Cytopathology 38(5):327-32 · November 2009with15 Reads
DOI: 10.1002/dc.21203 · Source: PubMed
Abstract
The gold standard to determine the cause of primary hyperparathyroidism (PHPT) is bilateral neck exploration. As most cases are caused by parathyroid adenoma, there is a movement toward preoperative localization of the abnormal gland by ultrasound and/or Tc(99)-sestamibi scan and minimally invasive parathyroidectomy. Nonpalpable thyroid nodules are common and cannot be differentiated from parathyroid lesions by imaging alone. This study examines cytopathologist-performed ultrasound-guided fine-needle aspiration (UG-FNA) in diagnosis of parathyroid lesions. Between January 1, 2007 and December 31, 2008, seven patients with PHPT or other parathyroid lesions with one or more sonographically-visible thyroid masses underwent cytopathologist-performed UG-FNA with immediate cytological evaluation (ICE). One mass was palpable and nine were nonpalpable. Three parathyroid adenomas, two benign colloid nodules, one papillary carcinoma, three parathyroid cysts, and one thyroid cyst were diagnosed. The nodules in three patients with parathyroid adenomas were identified as follicular lesion/neoplasm on ICE. Additional UG-FNA passes were made to obtain tissue for immunohistochemistry stains, which confirmed parathyroid origin. Two of these patients had a separate benign colloid nodule and one had a thyroid cyst diagnosed by UG-FNA. The PHPT patient with papillary carcinoma on UG-FNA had the malignancy confirmed at surgery and a sonographically occult parathyroid adenoma. The three patients with thyroid cysts identified by radiology were suspected of being parathyroid cysts on the basis of real-time sonographic features at the biopsy table. The clear cyst fluid obtained by UG-FNA had markedly elevated PTH. Cytopathologist-performed UG-FNA can distinguish between parathyroid and thyroid nodules in patients with suspected parathyroid lesions.
    • "Indeed, colloids and macrophages, which generally are found in a thyroid nodule, can be also be present in a parathyroid lesion. On the hand, parathyroid cells are generally smaller than thyroid cells and have less cytoplasm and more chromatin, but these are not a specific signs [16]. At surgery, the intraoperative frozen-section pathology in our patient suggested that the excised lesion was a PC and not a thyroid lesion. "
    [Show abstract] [Hide abstract] ABSTRACT: Parathyroid carcinoma (PC) is a rare endocrine malignancy. The tumor is mostly functioning, causing severe primary hyperparathyroidism, with high serum calcium and parathyroid hormone (PTH) levels. Nonfunctioning PC is extremely rare. We report a 50-year-old male patient who was referred to our Department for a right thyroid nodule, incidentally detected on carotid Doppler ultrasound scan, with a fine-needle aspiration cytology showing a follicular lesion. At the time of our evaluation, neck ultrasound showed a 1.3 cm right hypoechoic thyroid nodule with irregular margins and the absence of enlarged bilateral cervical lymph nodes. Thyroid function tests were normal. Serum calcium was normal and plasma PTH slightly above the upper limit of the normal range. The patients underwent right lobectomy. The intraoperative frozen-section pathological examination raised the suspicion of a PC. Definitive histology showed a markedly irregular infiltrative growth of the tumor with invasion of the thyroid tissue and cervical soft tissues. Immunostaining for thyroglobulin was negative, whereas staining for chromogranin A and PTH showed a strong reactivity. Based on the microscopic findings and the immunohistochemical profile, the tumor was diagnosed as a PC. Postoperative serum calcium and phosphate levels were in the normal range. One month after surgery, serum calcium and PTH were normal. Neck ultrasound and total body computed tomography scan were negative for local and metastatic disease. Eight months later, serum calcium was normal and plasma PTH level remained around the upper limit of normal range. Neck ultrasound did not show any pathological lesions. This is the first case of a nonfunctioning sporadic PC misdiagnosed prior of surgery as a follicular thyroid nodule. The parathyroid nature of the neck lesion could not be suspected before surgery. Fine-needle aspiration cytology (FNAC) may fail to distinguish a parathyroid tumor from a benign thyroid nodule because at FNAC, parathyroid and thyroid lesions have some morphological similarities. Histological criteria are not always sufficient for the differential diagnosis, which can definitely be established using immunohistochemistry.
    Full-text · Article · Sep 2015
    • "FNA cytology of the parathyroid might be misdiagnosed as Hürthle cell associated lesions of thyroid such as Hürthle cell thyroid neoplasm [9,151617; adenomatous thyroid nodules with Hürthle cell change; or chronic lymphocytic thyroiditis [18] because they might share some cytomorphologic similarities such as follicular structures, colloid-like material in the background [9]. Moreover, the presence of oncocytic cells and naked nuclei of chief cells in parathyroid cytologic specimen can be mimicking Hürthle cells and lymphocytes, respectively [19, 20]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background. Fine-needle aspiration (FNA) can cause misdiagnosis of cytomorphological findings between parathyroid and thyroid lesions. Case Presentation. A 31-year-old man presented with a palpable neck mass on the right thyroid lobe. FNA cytology was reported as intrathyroidal lymphoid hyperplasia. After 5 years, repeated FNA was done on the enlarged nodule with result of Hürthle cell lesion. Prior to right lobectomy, laboratories revealed elevated serum calcium and parathyroid hormone (PTH). Careful history taking revealed chronic knee pain and ossifying fibroma at the maxilla. Ultrasonography showed a 2.8 cm mass inferior to right thyroid lobe. Pathology from en bloc resection was parathyroid carcinoma and immunohistochemical study revealed positivity for PTH. Genetic analysis found somatic mutation of CDC73 gene in exon1 (c.70delG) which caused premature stop codon in amino acid 26 (p.Glu24Lysfs*2). The final diagnosis was hyperparathyroidism-jaw tumor syndrome. Conclusions. FNA cytology of parathyroid can mimic thyroid lesion. It is important to consider and correlate the entire information from clinical history, laboratory, imaging, and FNA.
    Full-text · Article · Aug 2014
    • "Another reason why this patient was misdiagnosed as having a thyroid nodule was that the fine needle aspiration cytology that was performed suggested a benign thyroid nodule. Under pathology examination, parathyroid cells are generally smaller than thyroid cells, have less cytoplasm and have much chromatin gathered inside in a dot shape, but this is not a critical feature [3]. In addition, although colloids or macrophage are generally observed in thyroid tissue, they are also often seen in parathyroid tissue, so it is difficult to rely entirely on fine needle aspirate-based cytology examination for accurate diagnosis. "
    [Show abstract] [Hide abstract] ABSTRACT: Primary hyperparathyroidism occurs as a result of isolated parathyroid adenoma in 80% to 85% of all cases. A (99m)technetium ((99m)Tc) sestamibi scan or neck ultrasonography is used to localize the neoplasm prior to surgical intervention. A 53-year-old female was referred for the exclusion of metabolic bone disease. She presented with low back pain that had persisted for the past 6 months and elevated serum alkaline phosphatase (1,253 IU/L). Four years previously, she had been diagnosed at a local hospital with a 2.3-cm thyroid nodule, which was determined to be pathologically benign. Radiofrequency ablation was performed at the same hospital because the nodule was still growing during the follow-up period 2 years before the visit to our hospital, and the procedure was unsuccessful in reducing the size of the nodule. The results of the laboratory tests in our hospital were as follows: serum calcium, 14.6 mg/dL; phosphorus, 3.5 mg/dL; and intact parathyroid hormone (iPTH), 1,911 pg/mL. Neck ultrasonography and (99m)Tc sestamibi scan detected a 5-cm parathyroid neoplasm in the left lower lobe of the patient's thyroid; left parathyroidectomy was performed. This case indicated that thyroid ultrasonographers and pathologists need to be experienced enough to differentiate a parathyroid neoplasm from a thyroid nodule; (99m)Tc sestamibi scan, serum calcium, and iPTH levels can help to establish the diagnosis of parathyroid neoplasm.
    Full-text · Article · Sep 2013
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