Difference between revisions of "Parathyroid adenoma"

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(rm 'diagnosis' category; now only the subtypes 'chief cell' and 'oxyphil')
 
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#redirect [[Parathyroid_glands#Parathyroid_adenoma]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Parathyroid adenoma intermed mag.jpg
| Width      =
| Caption    = Chief cell parathyroid adenoma (left of image) and unremarkable parathyroid gland (right of image). [[H&E stain]]. (WC)
| Synonyms  =
| Micro      = proliferation of parathyroid cells (chief cells, oxyphils or both) usually lacking adipose tissue, +/-rimmed by normal parathyroid gland, lack of destructive invasion of surround structures, lack of metastatic disease
| Subtypes  = chief cell, oxyphil, mixed
| LMDDx      = [[parathyroid hyperplasia]], [[parathyroid carcinoma]], [[lymph node]], [[thyroid gland]], [[Hürthle cell adenoma]] of thyroid (for ''oxyphil'' subtype)
| Stains    =
| IHC        = Ki-67 low
| EM        =
| Molecular  =
| IF        =
| Gross      =
| Grossing  =
| Site      = [[parathyroid gland]] ([[head and neck pathology|neck]]/[[mediastinum]])
| Assdx      = [[nephrolithiasis|renal stones]], osteitis fibrosa cystica
| Syndromes  = [[MEN 1|multiple endocrine neoplasia 1]], [[MEN 2A|multiple endocrine neoplasia 2A]]
| Clinicalhx =
| Signs      = constipation
| Symptoms  = bone pain, abdominal pain, lethargy, fatigue, memory loss
| Prevalence =
| Bloodwork  = increased parathyroid hormone, serum calcium increased
| Rads      =
| Endoscopy  =
| Prognosis  = benign
| Other      = depression, psychosis, delirium, coma, ataxia
| ClinDDx    = nodule (lymph node, other tumours), hyperparathyroidism ([[parathyroid hyperplasia]], [[parathyroid carcinoma]]), DDx of [[hypercalcemia]]
| Tx        = surgical excision
}}
'''Parathyroid adenoma''' is a common benign pathology of the [[parathyroid gland]].
 
==General==
*[[Clinical diagnosis]] - significant intraoperative drop of PTH after removal of suspected adenoma.<ref name=pmid26211860>{{Cite journal  | last1 = Özkul | first1 = MH. | last2 = Uyar | first2 = M. | last3 = Bayram | first3 = Ö. | last4 = Dikmen | first4 = B. | title = Parathyroid scintigraphy and minimal invasive surgery in parathyroid adenomas. | journal = Kulak Burun Bogaz Ihtis Derg | volume = 25 | issue = 4 | pages = 205-13 | month =  | year =  | doi =  | PMID = 26211860 }}</ref>
*Most common cause of [[primary hyperparathyroidism]].<ref name=Ref_PBoD8_1127>{{Ref PBoD8|1127}}</ref>
*May be associated with [[MEN 1]] or [[MEN 2A]].
 
MEN 1:
*Parathyroid adenoma.
*[[Pancreatic neuroendocrine tumour]].
*[[Pituitary adenoma]].
 
MEN 2A:
*Parathyroid adenoma.
*[[Medullary thyroid carcinoma]].
*[[Pheochromocytoma]].
 
===Subtypes===
Histologic subtyping:<ref name=pmid16203274>{{Cite journal  | last1 = Moran | first1 = CA. | last2 = Suster | first2 = S. | title = Primary parathyroid tumors of the mediastinum: a clinicopathologic and immunohistochemical study of 17 cases. | journal = Am J Clin Pathol | volume = 124 | issue = 5 | pages = 749-54 | month = Nov | year = 2005 | doi = 10.1309/WJEL-N05L-9A06-9DU0 | PMID = 16203274 }}</ref>
#Chief cell parathyroid adenoma.
#*Common.
#Oxyphil parathyroid adenoma.
#*Uncommon.<ref name=pmid15579742>{{Cite journal  | last1 = Fleischer | first1 = J. | last2 = Becker | first2 = C. | last3 = Hamele-Bena | first3 = D. | last4 = Breen | first4 = TL. | last5 = Silverberg | first5 = SJ. | title = Oxyphil parathyroid adenoma: a malignant presentation of a benign disease. | journal = J Clin Endocrinol Metab | volume = 89 | issue = 12 | pages = 5948-51 | month = Dec | year = 2004 | doi = 10.1210/jc.2004-1597 | PMID = 15579742 }}</ref>
#Mixed.
 
==Gross==
*One parathyroid gland is big... the others are small.
 
Note:
*There is a classification system by Perrier ''et al.'' that may be seen in radiology reports to describe the position of an adenoma.<ref name=pmid19148701>{{Cite journal  | last1 = Perrier | first1 = ND. | last2 = Edeiken | first2 = B. | last3 = Nunez | first3 = R. | last4 = Gayed | first4 = I. | last5 = Jimenez | first5 = C. | last6 = Busaidy | first6 = N. | last7 = Potylchansky | first7 = E. | last8 = Kee | first8 = S. | last9 = Vu | first9 = T. | title = A novel nomenclature to classify parathyroid adenomas. | journal = World J Surg | volume = 33 | issue = 3 | pages = 412-6 | month = Mar | year = 2009 | doi = 10.1007/s00268-008-9894-0 | PMID = 19148701 }}</ref>
 
===Weight===
It is common practice to weight parathyroid tissue:
*Parathyroid adenoma are: 0.55 +/- 0.52 grams.<ref name=pmid15240594>{{Cite journal  | last1 = Yao | first1 = K. | last2 = Singer | first2 = FR. | last3 = Roth | first3 = SI. | last4 = Sassoon | first4 = A. | last5 = Ye | first5 = C. | last6 = Giuliano | first6 = AE. | title = Weight of normal parathyroid glands in patients with parathyroid adenomas. | journal = J Clin Endocrinol Metab | volume = 89 | issue = 7 | pages = 3208-13 | month = Jul | year = 2004 | doi = 10.1210/jc.2003-031184 | PMID = 15240594 }}</ref>
*Normal parathyroids taken out with parathyroid adenomas are: 0.06 +/-0.03 grams.<ref name=pmid15240594/>
 
==Microscopic==
Features:
*Proliferation of parathyroid cells (chief cells, oxyphils or both) usually intermixed lacking adipose tissue.
*+/-Rim of normal parathyroid gland around the lesion<ref name=Ref_BITFS191>{{Ref BITFS|191}}</ref> with adipose tissue.
 
Note:
*Generally, it is impossible to discern between [[parathyroid adenoma]]s and [[parathyroid hyperplasia]]s by histology alone.<ref name=Ref_BITFS191>{{Ref BITFS|191}}</ref>
**One requires information on the size of the other glands to make the [[diagnosis]].
**Ideally, histologic findings should be correlated with the PTH serology.
 
DDx:
*[[Parathyroid hyperplasia]] - differentiated by clinical history.
*[[Parathyroid carcinoma]] - destructive invasion of surrounding tissue or far away mets, increased proliferative activity.
*[[Lymph node]].
*[[Hürthle cell adenoma]] - for oxyphil type (see below).
*[[Thyroid gland]].
 
===Chief cell parathyroid adenoma===
Features:<ref name=Ref_PBoD8_1127>{{Ref PBoD8|1127}}</ref>
*Chief cells - '''key feature''':
**Small central nucleus.
***Round with stippled chromatin - '''important'''.
**Moderate cytoplasm.
*+/-Scattered oxyphil cells:
**Large cells.
**Abundant cytoplasm.
*Architecture:
**Nests.
**Circular formations - often around capillaries (perivascular pseudo[[rosette]]s).
 
====Images====
<gallery>
Image:Parathyroid_adenoma_low_mag.jpg |Parathyroid adenoma - low mag. (WC/Nephron)
Image:Parathyroid_adenoma_high_mag.jpg |Parathyroid adenoma - high mag. (WC/Nephron)
</gallery>
 
===Oxyphil parathyroid adenoma===
Features:<ref name=Ref_PBoD8_1127>{{Ref PBoD8|1127}}</ref>
*Oxyphil cells:
**Large cells.
**Abundant cytoplasm.
 
DDx:
*[[Hürthle cell adenoma]] of the [[thyroid gland]].
 
====Image====
<gallery>
Image: Oxyphil parathyroid adenoma -- low mag.jpg | Oxyphil PA - low mag. (WC)
Image: Oxyphil parathyroid adenoma -- intermed mag.jpg | Oxyphil PA - intermed. mag. (WC)
Image: Oxyphil parathyroid adenoma - alt -- intermed mag.jpg | Oxyphil PA - intermed. mag. (WC)
Image: Oxyphil parathyroid adenoma - high mag.jpg | Oxyphil PA - high mag. (WC)
Image: Oxyphil parathyroid adenoma - very high mag.jpg | Oxyphil PA - very high mag. (WC)
</gallery>
<gallery>
Image: Parathyroid adenoma, mixed type -- high mag.jpg | PA, mixed type - high mag. (WC)
Image: Parathyroid adenoma, mixed type -- very high mag.jpg | PA, mixed type - very high mag. (WC)
Image: Parathyroid adenoma - oxyphil cells -- high mag.jpg | Oxyphil cells - high mag. (WC)
</gallery>
=====www=====
*[http://library.med.utah.edu/WebPath/jpeg4/ENDO091.jpg Parathyroid adenoma (med.utah.edu)].<ref>URL: [http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/enfrm.html http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/enfrm.html]. Accessed on: 6 December 2010.</ref>
 
==Sign out==
Note:
*One should not say "negative for malignancy".
 
<pre>
Parathyroid Gland (Submitted as "Right Superior Parathyroid Adenoma"), Excision:
- Parathyroid adenoma with adjacent normal parathyroid tissue.
</pre>
 
===Chief cell type===
<pre>
Parathyroid Gland, Excision:
- Chief cell parathyroid adenoma.
</pre>
 
<pre>
Parathyroid Gland, Excision:
- Chief cell parathyroid adenoma with adjacent normal parathyroid tissue.
</pre>
 
===Oxyphil type===
<pre>
Right Superior Parathyroid, Excision:
- Consistent with parathyroid adenoma (oxyphil type) with rim of
  normal appearing parathyroid tissue.
</pre>
 
====Tertiary hyperparathyroidism====
<pre>
A. Right Inferior Parathyroid, Excision:
- Cellular parathyroid tissue with a rim of normal-appearing
  parathyroid tissue, compatible with parathyroid adenoma.
 
B. Portion of Right Superior Parathyroid, Excision:
- Cellular parathyroid compatible with adenoma or hyperplasia.
</pre>
 
====Unclear history====
<pre>
Submitted as "Right Inferior Parathyroid", Excision:
- Hyperplastic appearing parathyroid tissue devoid of fat consisting of a
  mixture of chief cells and oncocytic cells, compatible with parathyroid
  adenoma in proper clinical context.
- Unremarkable parathyroid tissue.
</pre>
 
====Block letters====
<pre>
PARATHYROID GLAND, EXCISION:
- CHIEF CELL PARATHYROID ADENOMA.
</pre>
 
===Micro===
The section shows an adenoma consisting predominantly of chief cells. A rim of normal parathyroid is seen adjacent to the adenoma. A small amount of unremarkable adipose tissue is present.
 
==See also==
*[[Parathyroid glands]].
 
==References==
{{Reflist|1}}
 
[[Category:Diagnosis]]

Latest revision as of 16:44, 17 October 2019

Parathyroid adenoma
Diagnosis in short

Chief cell parathyroid adenoma (left of image) and unremarkable parathyroid gland (right of image). H&E stain. (WC)
LM proliferation of parathyroid cells (chief cells, oxyphils or both) usually lacking adipose tissue, +/-rimmed by normal parathyroid gland, lack of destructive invasion of surround structures, lack of metastatic disease
Subtypes chief cell, oxyphil, mixed
LM DDx parathyroid hyperplasia, parathyroid carcinoma, lymph node, thyroid gland, Hürthle cell adenoma of thyroid (for oxyphil subtype)
IHC Ki-67 low
Site parathyroid gland (neck/mediastinum)
Associated Dx renal stones, osteitis fibrosa cystica
Syndromes multiple endocrine neoplasia 1, multiple endocrine neoplasia 2A
Signs constipation
Symptoms bone pain, abdominal pain, lethargy, fatigue, memory loss
Blood work increased parathyroid hormone, serum calcium increased
Prognosis benign
Other depression, psychosis, delirium, coma, ataxia
Clin. DDx nodule (lymph node, other tumours), hyperparathyroidism (parathyroid hyperplasia, parathyroid carcinoma), DDx of hypercalcemia
Treatment surgical excision

Parathyroid adenoma is a common benign pathology of the parathyroid gland.

General

MEN 1:

MEN 2A:

Subtypes

Histologic subtyping:[3]

  1. Chief cell parathyroid adenoma.
    • Common.
  2. Oxyphil parathyroid adenoma.
  3. Mixed.

Gross

  • One parathyroid gland is big... the others are small.

Note:

  • There is a classification system by Perrier et al. that may be seen in radiology reports to describe the position of an adenoma.[5]

Weight

It is common practice to weight parathyroid tissue:

  • Parathyroid adenoma are: 0.55 +/- 0.52 grams.[6]
  • Normal parathyroids taken out with parathyroid adenomas are: 0.06 +/-0.03 grams.[6]

Microscopic

Features:

  • Proliferation of parathyroid cells (chief cells, oxyphils or both) usually intermixed lacking adipose tissue.
  • +/-Rim of normal parathyroid gland around the lesion[7] with adipose tissue.

Note:

DDx:

Chief cell parathyroid adenoma

Features:[2]

  • Chief cells - key feature:
    • Small central nucleus.
      • Round with stippled chromatin - important.
    • Moderate cytoplasm.
  • +/-Scattered oxyphil cells:
    • Large cells.
    • Abundant cytoplasm.
  • Architecture:
    • Nests.
    • Circular formations - often around capillaries (perivascular pseudorosettes).

Images

  • Parathyroid adenoma - low mag. (WC/Nephron)

  • Parathyroid adenoma - high mag. (WC/Nephron)

Oxyphil parathyroid adenoma

Features:[2]

  • Oxyphil cells:
    • Large cells.
    • Abundant cytoplasm.

DDx:

Image

  • Oxyphil PA - low mag. (WC)

  • Oxyphil PA - intermed. mag. (WC)

  • Oxyphil PA - intermed. mag. (WC)

  • Oxyphil PA - high mag. (WC)

  • Oxyphil PA - very high mag. (WC)

  • PA, mixed type - high mag. (WC)

  • PA, mixed type - very high mag. (WC)

  • Oxyphil cells - high mag. (WC)

www

Sign out

Note:

  • One should not say "negative for malignancy".
Parathyroid Gland (Submitted as "Right Superior Parathyroid Adenoma"), Excision:
- Parathyroid adenoma with adjacent normal parathyroid tissue.

Chief cell type

Parathyroid Gland, Excision:
- Chief cell parathyroid adenoma.

Parathyroid Gland, Excision:
- Chief cell parathyroid adenoma with adjacent normal parathyroid tissue.

Oxyphil type

Right Superior Parathyroid, Excision:
- Consistent with parathyroid adenoma (oxyphil type) with rim of 
  normal appearing parathyroid tissue.

Tertiary hyperparathyroidism

A. Right Inferior Parathyroid, Excision:
- Cellular parathyroid tissue with a rim of normal-appearing 
  parathyroid tissue, compatible with parathyroid adenoma.

B. Portion of Right Superior Parathyroid, Excision:
- Cellular parathyroid compatible with adenoma or hyperplasia.

Unclear history

Submitted as "Right Inferior Parathyroid", Excision:
- Hyperplastic appearing parathyroid tissue devoid of fat consisting of a
  mixture of chief cells and oncocytic cells, compatible with parathyroid 
  adenoma in proper clinical context.
- Unremarkable parathyroid tissue.

Block letters

PARATHYROID GLAND, EXCISION:
- CHIEF CELL PARATHYROID ADENOMA.

Micro

The section shows an adenoma consisting predominantly of chief cells. A rim of normal parathyroid is seen adjacent to the adenoma. A small amount of unremarkable adipose tissue is present.

See also

References

  1. ↑ Özkul, MH.; Uyar, M.; Bayram, Ö.; Dikmen, B.. "Parathyroid scintigraphy and minimal invasive surgery in parathyroid adenomas.". Kulak Burun Bogaz Ihtis Derg 25 (4): 205-13. PMID 26211860.
  2. ↑ 2.0 2.1 2.2 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1127. ISBN 978-1416031215.
  3. ↑ Moran, CA.; Suster, S. (Nov 2005). "Primary parathyroid tumors of the mediastinum: a clinicopathologic and immunohistochemical study of 17 cases.". Am J Clin Pathol 124 (5): 749-54. doi:10.1309/WJEL-N05L-9A06-9DU0. PMID 16203274.
  4. ↑ Fleischer, J.; Becker, C.; Hamele-Bena, D.; Breen, TL.; Silverberg, SJ. (Dec 2004). "Oxyphil parathyroid adenoma: a malignant presentation of a benign disease.". J Clin Endocrinol Metab 89 (12): 5948-51. doi:10.1210/jc.2004-1597. PMID 15579742.
  5. ↑ Perrier, ND.; Edeiken, B.; Nunez, R.; Gayed, I.; Jimenez, C.; Busaidy, N.; Potylchansky, E.; Kee, S. et al. (Mar 2009). "A novel nomenclature to classify parathyroid adenomas.". World J Surg 33 (3): 412-6. doi:10.1007/s00268-008-9894-0. PMID 19148701.
  6. ↑ 6.0 6.1 Yao, K.; Singer, FR.; Roth, SI.; Sassoon, A.; Ye, C.; Giuliano, AE. (Jul 2004). "Weight of normal parathyroid glands in patients with parathyroid adenomas.". J Clin Endocrinol Metab 89 (7): 3208-13. doi:10.1210/jc.2003-031184. PMID 15240594.
  7. ↑ 7.0 7.1 Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 191. ISBN 978-0781767798.
  8. ↑ URL: http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/enfrm.html. Accessed on: 6 December 2010.
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