Parathyroid adenoma

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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]

Microscopic

Features:

  • Proliferation of parathyroid cells (chief cells, oxyphils or both) usually intermixed lacking adipose tissue.
  • +/-Rim of normal parathyroid gland around the lesion[6] with adipose tissue.

Note:

  • Generally, it is impossible to discern between parathyroid adenomas and parathyroid hyperplasias by histology alone.[6]
    • 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:

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

Oxyphil parathyroid adenoma

Features:[2]

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

DDx:

Image

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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 Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 191. ISBN 978-0781767798.
  7. URL: http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/enfrm.html. Accessed on: 6 December 2010.