Difference between revisions of "Parathyroid glands"

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Parathyroid glands (view source)

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[[Image:Parathyroid gland high mag.jpg|thumb|right|280px|[[Micrograph]] of a parathyroid gland. [[H&E stain]].]]
The '''parathyroid glands''' are an endocrine organ that is important in calcium regulation.  They often make an appearance in the context of [[thyroid surgery]].   
The '''parathyroid glands''' are an endocrine organ that is important in calcium regulation.  They often make an appearance in the context of [[thyroid surgery]].   


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| high
| high
| high
| high
| persistent hyperparathyroidism after renal transplant<ref name=emed_hyperparathyroid_tertiary>URL: [http://emedicine.medscape.com/article/127351-overview#aw2aab6b6 http://emedicine.medscape.com/article/127351-overview#aw2aab6b6]. Accessed on: 24 January 2013.</ref>
| persistent hyperparathyroidism after renal transplant;<ref name=emed_hyperparathyroid_tertiary>URL: [http://emedicine.medscape.com/article/127351-overview#aw2aab6b6 http://emedicine.medscape.com/article/127351-overview#aw2aab6b6]. Accessed on: 24 January 2013.</ref> arises in the context of secondary hyperparathyroidism<ref name=pmid26163537>{{Cite journal  | last1 = Duan | first1 = K. | last2 = Gomez Hernandez | first2 = K. | last3 = Mete | first3 = O. | title = Clinicopathological correlates of hyperparathyroidism. | journal = J Clin Pathol | volume = 68 | issue = 10 | pages = 771-87 | month = Oct | year = 2015 | doi = 10.1136/jclinpath-2015-203186 | PMID = 26163537 }}</ref>
|}
|}
====Genetics====
Genes implicated in hyperparathyroidism:<ref name=pmid22187299>{{Cite journal  | last1 = Starker | first1 = LF. | last2 = Akerström | first2 = T. | last3 = Long | first3 = WD. | last4 = Delgado-Verdugo | first4 = A. | last5 = Donovan | first5 = P. | last6 = Udelsman | first6 = R. | last7 = Lifton | first7 = RP. | last8 = Carling | first8 = T. | title = Frequent germ-line mutations of the MEN1, CASR, and HRPT2/CDC73 genes in young patients with clinically non-familial primary hyperparathyroidism. | journal = Horm Cancer | volume = 3 | issue = 1-2 | pages = 44-51 | month = Apr | year = 2012 | doi = 10.1007/s12672-011-0100-8 | PMID = 22187299 }}</ref><ref name=pmid23652676>{{Cite journal  | last1 = Hendy | first1 = GN. | last2 = Cole | first2 = DE. | title = Genetic defects associated with familial and sporadic hyperparathyroidism. | journal = Front Horm Res | volume = 41 | issue =  | pages = 149-65 | month =  | year = 2013 | doi = 10.1159/000345675 | PMID = 23652676 }}</ref>
*MEN1.
*CASR.
*HRPT2/CDC73.
*CDKN1B.
*RET.


====Hypercalcemia DDx====
====Hypercalcemia DDx====
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Note:
Note:
*Hyperparathyroidism and FHH are assoc. with an increased PTH.<ref name=Ref_PBoD8_1129>{{ref PBoD8|1129}}</ref>
*Hyperparathyroidism and FHH are assoc. with an increased PTH.<ref name=Ref_PBoD8_1129>{{Ref PBoD8|1129}}</ref>
**Other causes are assoc. with a decreased PTH.
**Other causes are assoc. with a decreased PTH.


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*Familial isolated hypoparathyroidism.
*Familial isolated hypoparathyroidism.
*Congenital absence ([[DiGeorge syndrome]]).
*Congenital absence ([[DiGeorge syndrome]]).
*Drugs - [[proton pump inhibitors]].<ref name=pmid24736034>{{Cite journal  | last1 = Deroux | first1 = A. | last2 = Khouri | first2 = C. | last3 = Chabre | first3 = O. | last4 = Bouillet | first4 = L. | last5 = Casez | first5 = O. | title = Severe acute neurological symptoms related to proton pump inhibitors induced hypomagnesemia responsible for profound hypoparathyroidism with hypocalcemia. | journal = Clin Res Hepatol Gastroenterol | volume = 38 | issue = 5 | pages = e103-5 | month = Oct | year = 2014 | doi = 10.1016/j.clinre.2014.03.005 | PMID = 24736034 }}</ref><ref name=pmid25138239>{{Cite journal  | last1 = Toh | first1 = JW. | last2 = Ong | first2 = E. | last3 = Wilson | first3 = R. | title = Hypomagnesaemia associated with long-term use of proton pump inhibitors. | journal = Gastroenterol Rep (Oxf) | volume =  | issue =  | pages =  | month = Aug | year = 2014 | doi = 10.1093/gastro/gou054 | PMID = 25138239 }}</ref>


=Normal parathyroid glands=
=Normal parathyroid glands=
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****Increased with age, may be used to help differentiate from thyroid - '''key feature'''.
****Increased with age, may be used to help differentiate from thyroid - '''key feature'''.


Images:
====Images====
<gallery>
Image:Parathyroid_gland_intermed_mag.jpg | Parathyroid gland - intermed. mag. (WC)
Image:Parathyroid_gland_high_mag.jpg | Parathyroid gland - cropped - high mag. (WC)
Image:Parathyroid_gland_high_mag_cropped.jpg | Parathyroid gland - high mag. (WC)
</gallery>
www:
*[http://library.med.utah.edu/WebPath/ENDOHTML/ENDO031.html Parathyroid - med.utah.edu].
*[http://library.med.utah.edu/WebPath/ENDOHTML/ENDO031.html Parathyroid - med.utah.edu].
*[http://pathology.mc.duke.edu/research/PTH225.html Histology - several images. - pathology.mc.duke.edu].
*[http://pathology.mc.duke.edu/research/PTH225.html Histology - several images. - pathology.mc.duke.edu].
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====Parathyroid cell types====
====Parathyroid cell types====
{| class="wikitable"
{| class="wikitable"
| '''Name'''
! Name
| '''Staining (cytoplasm)'''
! Staining (cytoplasm)
| '''Quantity of cells'''
! Quantity of cells  
|  '''Cytoplasm (quantity)'''
! Cytoplasm (quantity)  
| '''Function'''
! Function
! Image
|-  
|-  
| (parathyroid) chief cells   
| (parathyroid) chief cells   
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| moderate  
| moderate  
| manufacture parathyroid <br>hormone (PTH)
| manufacture parathyroid <br>hormone (PTH)
| [[Image:Parathyroid adenoma - chief cells -- high mag.jpg|thumb|center|85px|Chief cells (WC)]]
|-  
|-  
| oxyphil cells   
| oxyphil cells   
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| abundant  
| abundant  
| ?
| ?
| [[Image:Parathyroid adenoma - oxyphil cells -- high mag.jpg|thumb|center|85px|Oxyphil cells (WC)]]
|}
|}
Notes:
Notes:
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**Hyperchromatic.
**Hyperchromatic.


See: [http://instruction.cvhs.okstate.edu/Histology/HistologyReference/imagesco/parathyroid2F.jpg Parathyroid image (okstate.edu)].
Notes:
*Thyroid often has birefringent (calcium oxalate) crystals (60 of 80 cases) whereas parathyroid less often does (2 or 20 cases).<ref name=pmid24618617>{{cite journal |authors=Wong KS, Lewis JS, Gottipati S, Chernock RD |title=Utility of birefringent crystal identification by polarized light microscopy in distinguishing thyroid from parathyroid tissue on intraoperative frozen sections |journal=Am J Surg Pathol |volume=38 |issue=9 |pages=1212–9 |date=September 2014 |pmid=24618617 |doi=10.1097/PAS.0000000000000204 |url=}}</ref>
*Thyroid usually follicular - though parathyroid occasionally is pseudofollicular.


====Parathyroid versus lymphoid tissue====
====Parathyroid versus lymphoid tissue====
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*[http://www.deltagen.com/target/histologyatlas/atlas_files/endocrine/parathyroid_and_thyroid_glands_20x.jpg Parathyroid image (deltagen.com)].
*[http://www.deltagen.com/target/histologyatlas/atlas_files/endocrine/parathyroid_and_thyroid_glands_20x.jpg Parathyroid image (deltagen.com)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770637/figure/f1/ Parathyroid gland (nih.gov)].<ref name=pmid15790694>{{Cite journal  | last1 = Johnson | first1 = SJ. | last2 = Sheffield | first2 = EA. | last3 = McNicol | first3 = AM. | title = Best practice no 183. Examination of parathyroid gland specimens. | journal = J Clin Pathol | volume = 58 | issue = 4 | pages = 338-42 | month = Apr | year = 2005 | doi = 10.1136/jcp.2002.002550 | PMID = 15790694 | pmc = 1770637 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770637/figure/f1/ Parathyroid gland (nih.gov)].<ref name=pmid15790694>{{Cite journal  | last1 = Johnson | first1 = SJ. | last2 = Sheffield | first2 = EA. | last3 = McNicol | first3 = AM. | title = Best practice no 183. Examination of parathyroid gland specimens. | journal = J Clin Pathol | volume = 58 | issue = 4 | pages = 338-42 | month = Apr | year = 2005 | doi = 10.1136/jcp.2002.002550 | PMID = 15790694 | pmc = 1770637 }}</ref>
===IHC===
*GATA3 +ve (>98%<ref name=pmid27097544>{{Cite journal  | last1 = Takada | first1 = N. | last2 = Hirokawa | first2 = M. | last3 = Suzuki | first3 = A. | last4 = Higuchi | first4 = M. | last5 = Kuma | first5 = S. | last6 = Miyauchi | first6 = A. | title = Diagnostic value of GATA-3 in cytological identification of parathyroid tissues. | journal = Endocr J | volume = 63 | issue = 7 | pages = 621-6 | month = Jul | year = 2016 | doi = 10.1507/endocrj.EJ15-0700 | PMID = 27097544 }}</ref>).
*PTH -ve/+ve (~33%<ref name=pmid27097544/>).
*Chromogranin A +ve (~80%<ref name=pmid27097544/>).
*AE1/AE3 +ve.{{fact}}<!-- {{Cite journal  | last1 = Piciu | first1 = D. | last2 = Irimie | first2 = A. | last3 = Kontogeorgos | first3 = G. | last4 = Piciu | first4 = A. | last5 = Buiga | first5 = R. | title = Highly aggressive pathology of non-functional parathyroid carcinoma. | journal = Orphanet J Rare Dis | volume = 8 | issue =  | pages = 115 | month = Aug | year = 2013 | doi = 10.1186/1750-1172-8-115 | PMID = 23915575 }} -->


=Specific entities=
=Specific entities=
==Parathyroid hyperplasia==
==Parathyroid hyperplasia==
===General===
{{Main|Parathyroid hyperplasia}}
*Chief cell hyperplasia - associated with MEN 1, MEN 2A.<ref>URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970475-2 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970475-2]. Accessed on: 29 July 2010.</ref>
*Parathyroid hyperplasia - classically assoc. with renal failure.
 
===Gross===
*Classically all parathyroid glands are involved; however, some may be spared making it difficult to differentiate this from parathyroid adenoma.<ref name=Ref_PBoD8_1128>{{Ref PBoD8|1128}}</ref>
 
===Microscopic===
Features:<ref name=Ref_PBoD8_1128>{{Ref PBoD8|1128}}</ref>
*Classically have abundant adipose tissue.
*+/-Water-clear cells ("water-clear cell hyperplasia").
 
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 of the size of the other glands to make the diagnosis.
 
DDx:
*[[Parathyroid adenoma]] - classically have a rim of normal parathyroid gland around it.


==Parathyroid adenoma==
==Parathyroid adenoma==
===General===
{{Main|Parathyroid adenoma}}
*One parathyroid is big... the others are small.
*Associated with [[MEN 1]] and [[MEN 2A]].
 
MEN 1:
*Parathyroid adenoma.
*[[Pancreatic neuroendocrine tumour]].
*[[Pituitary adenoma]].
 
MEN 2A:
*Parathyroid adenoma.
*[[Medullary thyroid carcinoma]].
*[[Pheochromocytoma]].
 
====Subtypes====
#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>
 
===Microscopic===
Features - general:
*Classically have a rim of normal parathyroid gland around it.<ref name=Ref_BITFS191>{{Ref BITFS|191}}</ref>
 
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 of the size of the other glands to make the diagnosis.
 
====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).
 
<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:
*[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===
<pre>
PARATHRYOID GLAND, EXCISION:
- CHIEF CELL PARATHYROID ADENOMA.
</pre>
Note:
*One should not say "negative for malignancy".


==Parathyroid carcinoma==
==Parathyroid carcinoma==
===General===
{{Main|Parathyroid carcinoma}}
*Extremely rare.
 
===Microscopic===
Features:<ref>{{Ref PBoD8|1128}}</ref>
*Histologically normal parathyroid cells.
**Cytologic features not reliable for diagnosis.
*Fibrous capsule.
*Invasion of surrounding tissue - '''key feature'''.
*+/-[[Metastasis]] - '''diagnostic feature'''.
 
Note:
*Diagnosis of ''parathyroid carcinoma'' is like that of ''malignant [[pheochromocytoma]]'' - cytology useless, tissue invasion and metastases are the key features.
 
Image:
*[http://emedicine.medscape.com/article/280908-overview Parathyroid carcinoma (medscape.com)].


=See also=
=See also=
Michael
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