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      Atypical ultrasound features of parathyroid tumours may bear a relationship to their clinical and biochemical presentation

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          Abstract

          Objectives

          To describe atypical ultrasound features of parathyroid lesions and correlate them with clinical presentation and histopathology.

          Materials and methods

          Retrospective review of 264 patients with primary hyperparathyroidism who underwent ultrasound imaging prior to parathyroidectomy was performed. Patients with atypical ultrasound findings (n = 26) were identified; imaging findings were correlated with clinical presentation and histopathology.

          Results

          Twenty-one (80 %) lesions were adenomas, two (8 %) were adenomas with cellular atypia, and three (11.5 %) were carcinomas. Seventeen (65 %) lesions showed cystic change; five (19 %) of them had >50 % cystic change. These lesions were adenomas with cystic degeneration. Cystic degeneration had significant positive correlation with the lesion size and PTH level, but cystic adenomas correlated negatively with lesion weight. Six (23 %) lesions were isoechoic and one (4 %) was hyperechoic; histology predominantly revealed haemorrhage, hyalinisation and fibrosis; one lesion showed fat deposition and another had multiple granulomas within the adenoma. Twenty (83 %) lesions had heterogeneous echotexture and showed combinations of acinar dilatation, necrosis, haemorrhage and fibrosis. Heterogeneous lesions tended to be significantly larger and heavier, and they were associated with higher PTH levels. Four (15 %) lesions had calcifications. Scintigraphy was concordant in 22 (96 %), n = 23. One scintigraphy-negative lesion was a cystic parathyroid adenoma.

          Conclusion

          Atypical ultrasound features of parathyroid lesions pose a diagnostic challenge. Awareness of these features would help improve lesion detection.

          Teaching points

          1. Cystic change is significantly related to the size, weight and measured parathyroid hormone levels.

          2. Cystic change in parathyroid tumours indicated a slightly higher risk of malignancy.

          3. Heterogeneous parathyroid adenomas are larger in size and heavier, and they have higher PTH levels.

          4. Awareness of atypical ultrasound features will improve preoperative clinical prediction.

          Related collections

          Most cited references 16

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          Parathyroid imaging: technique and role in the preoperative evaluation of primary hyperparathyroidism.

          This article discusses the commonly used techniques for imaging the parathyroid glands and their role in the preoperative evaluation of patients with primary hyperparathyroidism. The importance of sonography and sestamibi scintigraphy in the preoperative evaluation of patients with primary hyperthyroidism has increased with the adoption of minimally invasive parathyroidectomy techniques at most medical centers. When the results of these studies are concordant, the cure rates of minimally invasive surgery equal those of traditional bilateral neck exploration.
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            Cystic parathyroid lesions: functional and nonfunctional parathyroid cysts.

            Functional parathyroid cysts (FPCs) and nonfunctional parathyroid cysts (NPCs) are 2 distinct clinical and histologic entities. Review of prospective clinical database records. Tertiary academic center. Patients enrolled in a prospective surgical database between January 1, 1990, and May 31, 2007. Cervical exploration for primary hyperparathyroidism or cervical mass. Age, sex, morbidity, imaging results, pathologic findings, cyst characteristics (size, location, and fluid), and perioperative calcium and parathyroid hormone levels. Cystic parathyroid lesions were found in 48 of 1769 patients (3%) studied. Functional parathyroid cysts were more common than NPCs, arising in 41 of 48 patients (85%), and showed no predisposition for sex or embryologic origin. Single-photon emission computed tomographic imaging failed to localize FPCs in 12 of 37 patients (32%). The fluid in FPCs was clear or colorless in 9 of 15 characterized specimens (60%). Rupture of cystic parathyroid lesions during resection was associated with prolonged elevation of intraoperative parathyroid hormone levels (P =.045). Cystic parathyroid lesions weighing 4 g or more were associated with the development of postoperative symptomatic hypocalcemia (P =.03). Functional parathyroid cysts occurred exclusively in adenomas with cystic change, whereas NPCs (with 1 exception) were without associated adenoma on final histologic examination. Cystic parathyroid lesions often contain turbid or colored fluid, and FPCs are more common than NPCs. Neck cysts of uncertain origin should be diagnostically aspirated for parathyroid hormone content. During resection, cyst rupture should be avoided, and patients with large cysts should be managed expectantly to forestall the development of symptomatic hypocalcemia. Functional parathyroid cysts and NPCs are likely 2 separate clinical and histologic entities.
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              Cystic parathyroid adenoma: sonographic features and correlation with 99mTc-sestamibi SPECT findings.

              The purpose of this study was to describe the typical ultrasound features of cystic parathyroid adenoma. A review of a surgical database and electronic medical records from 2006 to 2009 identified the cases of 15 patients who underwent preoperative cervical sonography for primary hyperparathyroidism with subsequent resection of pathologically proven parathyroid adenoma with predominantly cystic components. Two radiologists retrospectively evaluated the preoperative ultrasound images and assessed for cyst complexity, size, location, and color Doppler vascularity. Technetium-99m-sestamibi SPECT findings, surgical and pathologic reports, and the results of parathyroid hormone assay of the cyst fluid also were reviewed. Most of the cystic adenomas (14/15, 93%) were deep or inferolateral to the adjacent thyroid. The same percentage were elongated and had peripheral nodular components. An echogenic border separating the adenoma from the overlying thyroid was identified in 9 of 15 patients (60%). Color Doppler examination of 14 patients showed feeding vessels with internal color flow to the solid components in 10 patients (71%). Six of 14 patients underwent preoperative or intraoperative sampling of cyst fluid, and the assay showed the parathyroid hormone levels ranged from 1,198 to greater than 5,000 pg/mL. Fourteen of 15 patients underwent preoperative sestamibi SPECT, and the adenoma was definitively localized in four patients (29%). The accuracy of preoperative localization improved to 79% (11/14) when sestamibi SPECT scans were interpreted in correlation with cervical ultrasound images. Awareness of typical sonographic features (location, color Doppler vascularity) may aid radiologists in preoperative localization of parathyroid adenomas, even when cystic degeneration occurs. In cases in which imaging or clinical features are equivocal, the results of cyst fluid sampling and parathyroid hormone assay are confirmatory.
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                Author and article information

                Contributors
                +91-416-2283012 , anuradhachandramohan@gmail.com
                +91-416-2283012 , kirthi86s@yahoo.com
                +91-416-2283012 , johnreetu@yahoo.com
                +91-416-2283124 , mtm2005@cmcvellore.ac.in
                +91-416-2282609 , abrahamdt@gmail.com
                +91-416-2283571 , thomasvpaul@yahoo.com
                +91-416-2282694 , nihal_thomas@yahoo.com
                +91-416-2282609 , mjpaul@cmcvellore.ac.in
                Journal
                Insights Imaging
                Insights Imaging
                Insights into Imaging
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1869-4101
                29 November 2013
                29 November 2013
                February 2014
                : 5
                : 1
                : 103-111
                Affiliations
                [ ]Department of Radiology, Christian Medical College, Vellore, Tamil Nadu India 632004
                [ ]Department of Pathology, Christian Medical College, Vellore, Tamil Nadu India 632004
                [ ]Department of Endocrine surgery, Christian Medical College, Vellore, Tamil Nadu India 632004
                [ ]Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu India 632004
                [ ]Department of Radiology, Christian Medical College, Vellore, Tamil Nadu 632002 India
                Article
                297
                10.1007/s13244-013-0297-x
                3948912
                24293304
                © The Author(s) 2013

                Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

                Categories
                Original Article
                Custom metadata
                © The Author(s) 2014

                Radiology & Imaging

                atypical features, parathyroid, ultrasound, histopathology

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