Needle aspiration of nonfunctioning parathyroid cysts

Parathyroid cysts, appearing as thyroid masses, have been previously diagnosed at operation or by permanent histologic specimens. With the advent of ultrasound and fine-needle biopsies, these very rare cysts can now be diagnosed by needle aspiration. The pearly clear fluid of a parathyroid cyst contrasts with the sanguineous or even chocolate-brown fluid of a thyroid cyst. The high parathyroid hormone (PTH) level of the fluid confirms the diagnosis, and a blood calcium level determines its function or nonfunction in the patients. Of our seven nonfunctioning parathyroid cysts, the first three were diagnosed by operation and the other four by needle aspirations. The PTH determination ranged from 20,000 to 42,000 pg/mL. We suggest that needle aspiration, rather than operation, be the treatment of choice.     

A giant nonfunctioning parathyroid cyst

Summary A case of a giant nonfunctioning parathyroid cyst is presented. The diagnosis was missed preoperatively, due to unfamiliarity with this pathology. Functioning parathyroid cysts cause hyperparathyroidism and are easy to diagnose. Nonfunctioning parathyroid cysts produce only a mass in the neck, without other symptoms. From the literature it appears that they are seldom diagnosed preoperatively. However, aspiration of clear, colorless watery fluid should lead to a correct diagnosis. This case is interesting because of its rarity and of the giant size of the cyst. No evidence of a parathyroid cyst of these dimensions has been found in the literature. This case also proves that parathyroid cysts may recur after aspiration; thus aspiration is not always the definite treatment of these cysts.Paper presented at the Autumn Meeting of the Belgian Society for Plastic, Reconstructive and Esthetic Surgery, Leuven, Belgium, November 4, 1989 Offprint requests to: Prof. G. Matton     

Benign parathyroid cyst causing vocal fold paralysis: a case report and review of the literature

BACKGROUND: Parathyroid cysts are uncommon, frequently asymptomatic lesions of the neck and superior mediastinum. Symptomatic parathyroid cysts are very rare, with roughly only 200 cases reported in the literature. Of these, only nine cases have been reported with recurrent laryngeal nerve (RLN) paralysis METHODS: We report a case of a 49-year-old man initially seen with a 6-month history of worsening hoarseness. Physical examination revealed a palpable 3-cm, firm, smooth, nontender mass of the right thyroid lobe. Fiberoscopic laryngoscopy showed right vocal cord immobility consistent with RLN paralysis. After CT and fine-needle aspiration of the mass, the patient underwent a right thyroid lobectomy. During surgery, the recurrent laryngeal nerve was found to be stretched and adherent to a right inferior lobe mass. RESULTS: Histologic analysis of the surgical specimen revealed a benign parathyroid adenomatous cyst. Postoperatively, the patient's voice improved markedly. This case represents an extremely rare return of function of the RLN after cyst removal. CONCLUSION: Parathyroid cysts should be included in the differential diagnosis for vocal fold paralysis.     

Parathyroid cysts

Fourteen new cases of parathyroid cyst are presented. Two distinct groups were identified: functioning and nonfunctioning. Patients with functioning cysts presented with hypercalcemia, tended to be men and were older. Patients with nonfunctioning cysts were all women, had normocalcemia and all presented with neck masses. Ultrasonography proved useful while radionuclide thyroid scans were often misleading. In the functioning group removal of parathyroid cysts resulted in postoperative normocalcemia in all cases. In the nonfunctioning cysts thyroid lobectomy was performed in five of six instances. Parathyroid cysts usually contain clear or serous fluid and are surrounded by a well-delineated plane of dissection. We believe that preoperative aspiration of cystic neck masses and consideration of the diagnosis of parathyroid cysts may avoid needless thyroid lobectomy.     

Parathyroid cysts of the neck and mediastinum. Case report

Five cases of parathyroid cyst are presented and the literature concerning this rare entity is reviewed. Three of the five cysts were located in the neck and were non-functioning. The other two were in the anterior mediastinum and functioning, and indeed were associated with hypercalcemic crisis. Four cases were treated surgically, and in one non-functioning parathyroid cyst both diagnosis and treatment were accomplished with fine-needle aspiration. The cystic appearance, color of the fluid contents, high content of parathyroid hormone and histologic features distinguish parathyroid cyst from the much commoner thyroid cyst. Non-functioning parathyroid cysts can be treated with fine-needle aspiration, whereas functioning cysts require surgical removal.     

Mediastinal parathyroid cyst with tracheal constriction

A 63-year-old man visiting a physician for slight dyspnea, attributed to a lump on his neck, was found in ultrasonography and computed tomography to have a cyst extending from the left lobe of the thyroid gland to the superior mediastinum. Radiography showed right deviation of the trachea. The cyst disappeared after fine-needle aspiration, but cyst fluid subsequently reaccumulated and he was admitted to our hospital. No abnormalities were detected in tests of thyroid and parathyroid function or blood chemical analysis. The cyst was surgically removed and diagnosed as a nonfunctioning parathyroid cyst, based on the high-intact parathyroid hormone in cyst fluid. The patient recovered fully and has shown no recurrence in the 11 months to data since surgery.     

Mediastinal parathyroid cyst with tracheal constriction.

A 63-year-old man visiting a physician for slight dyspnea, attributed to a lump on his neck, was found in ultrasonography and computed tomography to have a cyst extending from the left lobe of the thyroid gland to the superior mediastinum. Radiography showed right deviation of the trachea. The cyst disappeared after fine-needle aspiration, but cyst fluid subsequently reaccumulated and he was admitted to our hospital. No abnormalities were detected in tests of thyroid and parathyroid function or blood chemical analysis. The cyst was surgically removed and diagnosed as a nonfunctioning parathyroid cyst, based on the high-intact parathyroid hormone in cyst fluid. The patient recovered fully and has shown no recurrence in the 11 months to data since surgery.     

Parathyroid cyst: diagnosis and treatment of an unusual surgical problem

A case of parathyroid cyst is reported in which the diagnosis was suggested when watery, clear fluid was aspirated from a mass found in the anterior region of the neck of a 34-year-old woman on routine medical examination. The diagnosis was confirmed by measurement of the parathormone content in the cyst fluid and by histologic examination of the cyst wall. Although rare, parathyroid cyst should be considered in the differential diagnosis of cysts in the anterior compartment of the neck. Surgery has been the usual treatment of such cysts, but several reports have been published in which repeated aspiration resulted in the disappearance of the cyst. If conservative treatment of a parathyroid cyst is unsuccessful, the cyst should be removed surgically.     

Hypercalcemic crisis secondary to a functioning parathyroid cyst

A case of hypercalcemic crisis secondary to a large functioning parathyroid cyst is presented. Because none of the theories about the origin of parathyroid cysts are well substantiated or accepted, these cysts should be referred to simply as parathyroid cysts, functional or nonfunctional.     

Parathyroid cysts

Cystic neck masses may be accurately diagnosed by sonography, and some nonfunctioning parathyroid cysts can be cured by percutaneous aspiration. Primary hyperparathyroidism should be considered in all patients with cystic neck masses. Parathyroid cysts can often be recognized from the characteristics of the cyst fluid which is usually clear and colorless, contains elevated parathyroid hormone levels and normal or low thyroid hormone levels, and may contain parathyroid cells. Parathyroid cysts may be multiple; all four parathyroid glands should therefore be identified and appropriately removed or hyperparathyroidism may persist.     

Parathyroid cysts, a rare condition: a case report and review of the literature

Parathyroid cysts are a rare medical condition, that is why they represent a diagnostic and therapeutic challenge for the practitioner. The cysts are often small in diameter, measuring a few millimeters, but in some cases they are centimetric in size. There are 2 types of parathyroid cysts, according to their activity: the nonfunctioning (essential) and the functioning (adenomatous) forms, the last one being responsible of hyperparathyroidism. We report a case of nonfunctioning symptomatic parathyroid cyst in a 36-year old woman revealed by an anterior cervical tumefaction focusing on the pre-operative diagnosis and the management of it regarding the various therapeutic methods described in the literature.     

Poor predictability of prenatal ultrasonography for a nonfunctional kidney

We present 2 cases in which the diagnosis of a unilateral nonfunctioning kidney was not anticipated. The first case appeared to be simple, antenatally diagnosed, unilateral hydronephrosis with adequate parenchyma. However, at 3 months postnatally, it was found to be nonfunctional, most likely secondary to early high-grade obstruction. The second case presented prenatally as a left hydronephrotic kidney with parenchymal cysts, and the right kidney showed only mild parenchymal cystic changes. By 6 months, however, the right kidney was nonfunctional. These cases emphasize the need for coordinated prenatal and postnatal care. The sonographic appearance of renal dysplasia is variable (in size, number of cysts, and degree of hydronephrosis), depending on the point at which it is evaluated during the disease course. Subtle signs of dysplasia, such as increased echogenicity, may be the only warning sign of a nonfunctioning kidney, for which one should have a high index of suspicion.     

Lymphoepithelial cyst in the pancreas: a case report and review of the literature

BACKGROUND: Lymphoepithelial cysts of the pancreas constitute a rare clinicopathologic entity. CASE REPORT: We report a case of lymphoepithelial cyst of the pancreas and review the world literature. RESULTS: Lymphoepithelial cysts are true pancreatic cysts lined by squamous epithelium and surrounded by mature lymphoid tissue. The cyst arises typically in middle aged men, and is usually asymptomatic or causes nonspecific abdominal complaints. There is no specific serologic marker for this entity. None of its radiologic characteristics can help differentiate it from other cystic lesions of the pancreas. Fine-needle aspiration cytology may be able to suggest its benign nature and identify it as a true cyst of the pancreas. The outcome after surgical excision is uniformly good with good symptom control and no recurrences. RECOMMENDATIONS: In the symptomatic patient or the asymptomatic patient with acceptable surgical risk a simple cyst excision should be performed after verification of the diagnosis with frozen section. In the asymptomatic patient with a high surgical risk, in whom fine-needle aspiration suggests the diagnosis of a lymphoepithelial cyst, observation of the lesion is recommended. When simple cyst excision is technically not possible, extensive resections/reconstructions should be avoided and drainage/bypass procedures may be considered.     

非功能性甲状旁腺囊肿的鉴别诊断与治疗

目的探讨非功能性甲状旁腺囊肿的鉴别诊断与治疗。方法回顾性分析中国医科大学附属盛京医院普外科2003年1月至2013年4月期间收治的6例非功能性甲状旁腺囊肿患者的临床资料。结果6例患者术前均未确诊,其中4例诊断为甲状腺囊肿,1例笼统诊断为颈部肿物,1例仅注意了甲状腺病变。6例均行手术治疗,其中5例行左甲状旁腺囊肿切除术,1例同时行甲状腺癌根治、左甲状旁腺囊肿切除术。术后病理报告5例为甲状旁腺囊肿,1例为甲状旁腺囊肿合并右甲状腺乳头状微小癌。2例患者失访;4例患者随访9～24个月,平均19个月,均无甲状旁腺囊肿及甲状腺癌的复发或转移。结论非功能性甲状旁腺囊肿是真正意义上的甲状旁腺囊肿,临床少见,术前确诊率低。甲状旁腺囊肿切除术是一种安全而有效的治疗手段。     

Devastating complications from alcohol cauterization of recurrent Rathke cleft cyst. Case report

Rathke cleft cysts are commonly found on autopsy but are seldom symptomatic. Conventional treatment of these lesions consists of transsphenoidal drainage with partial excision of the cyst, and recurrence is rare. Alternatively, the instillation of absolute alcohol into the cyst has been described in several reports, with no complications. The authors report on a woman with Rathke cleft cyst that recurred three times after the initial treatment; the lesion was treated with alcohol cauterization on the final recurrence with devastating complications. This 51-year-old woman presented in 1992 with headaches and visual disturbances. Admission magnetic resonance imaging revealed a sellar/suprasellar lesion that was treated with conventional surgery and was subsequently confirmed to be a Rathke cleft cyst. The patient again presented with recurrence of the cyst at 22, 26, and 31 months after the initial presentation. On the final recurrence the cyst was treated with alcohol cauterization. Postoperatively, the patient awoke blind and suffered a seizure from leakage of the alcohol. The patient remains completely blind in both eyes and is also anosmic and has left lid ptosis and exotropia, which signify damage to the first through third cranial nerves. Rathke cleft cysts have been known to recur after primary surgery; however, this is the first report of a single cyst recurring three times despite conventional surgical treatment. Additionally, this is the first report in which devastating complications from alcohol cauterization of the cyst have been described. The authors therefore advocate caution when attempting alcohol cauterization and advise that meticulous care be taken to ensure the patency of the cyst.     

Parathyroid Cyst: Often Mistaken for a Thyroid Cyst

Introduction Parathyroid cysts are rare but clinically significant lesions. They can be functional, mistaken for a thyroid cyst, and/or managed nonoperatively on occasion. Methods We identified seven patients (1 male, 6 females) with the diagnosis of parathyroid cyst from 1998 to 2003. Results Altogether, 33% of the patients had functional cysts. Sestamibi scans were performed in three of the seven patients, including two with functional cysts; none showed focal uptake. In toto, six of the seven cysts (86%) were found in an inferior parathyroid gland. All of the cysts had crystal-clear aspirate. C-terminal parathormone (PTH) levels were obtained from the aspirate from five of the seven (71%) patients. The mean level was 269,736 pg/ml (1970–1,268,074 pg/ml). Surgery was performed in three of the seven (43%) patients. All patients who underwent surgery improved postoperatively based on symptoms and serum levels of calcium and PTH. The four patients (57%) who were treated nonoperatively were subjected to aspiration alone; three (75%) of those patients required multiple aspirations. Conclusions Most parathyroid cysts are nonfunctional and are rarely symptomatic. They are usually located in an inferior gland. If aspirated, most of the cysts reaccumulate fluid. Operative management is usually straightforward and alleviates symptoms and any biochemical abnormalities caused by the cyst. This study was presented as a poster at the meeting of the American Thyroid Association, Vancouver, BC, October 2004     

Hormone inactive parathyroid cyst: rare differential diagnosis in the evaluation of cervical cysts

Parathyroid cysts are a very rare disease entity. Hormone activity is uncommon and they usually present without any clinical symptoms. The differential diagnosis of cystic neck masses should nevertheless include parathyroid cysts as surgical therapy can be very effective. We report the case of a 57-year-old patient presenting to our department with a hormone inactive parathyroid cyst. Final diagnosis was achieved eventually after histological examination of the resected specimen, which is the reason for evaluating the current data for preoperative management of this disease entity in this case report.     

Diagnosing aneurysmal and unicameral bone cysts with magnetic resonance imaging

The differential between aneurysmal bone cysts and unicameral bone cysts usually is clear clinically and radiographically. Occasionally there are cases in which the diagnosis is not clear. Because natural history and treatment are different, the ability to distinguish between these two entities before surgery is important. The authors reviewed, in a blinded fashion, the preoperative magnetic resonance images to investigate criteria that could be used to differentiate between the two lesions. All patients had operative or pathologic confirmation of an aneurysmal bone cyst or unicameral bone cyst. The authors analyzed the preoperative magnetic resonance images of 14 patients with diagnostically difficult bone cysts (eight children with unicameral bone cysts and six children with aneurysmal bone cysts) and correlated these findings with diagnosis after biopsy or cyst aspiration and contrast injection. The presence of a double density fluid level within the lesion strongly indicated that the lesion was an aneurysmal bone cyst, rather than a unicameral bone cyst. Other criteria that suggested the lesion was an aneurysmal bone cyst were the presence of septations within the lesion and signal characteristics of low intensity on T1 images and high intensity on T2 images. The authors identified a way of helping to differentiate between aneurysmal bone cysts and unicameral bone cysts on magnetic resonance images. Double density fluid level, septation, and low signal on T1 images and high signal on T2 images strongly suggest the bone cyst in question is an aneurysmal bone cyst, rather than a unicameral bone cyst. This may be helpful before surgery for the child who has a cystic lesion for which radiographic features do not allow a clear differentiation of unicameral bone cyst from aneurysmal bone cyst.     

Thoracoscopic resection of a giant mediastinal parathyroid cyst

Parathyroid cysts are a rare situation, unusually in the mediastinum. The preoperative diagnosis could be more difficult in some atypical topographies and imaging characteristics in particular in case of huge mediastinal cyst. In the following years traditionally, in case of intrathoracic parathyroid cysts, sternotomy or thoracotomy have been the preferred approaches. We report a case of an older patient with a huge mediastinal parathyroid cyst removed successfully using videothoracoscopy.     

Intradiploic arachnoid cyst identified by diffusion-weighted magnetic resonance imaging--case report

A 72-year-old woman presented with an intradiploic arachnoid cyst in the occipital intradiploic space which was found incidentally by magnetic resonance (MR) imaging. Computed tomography revealed a widened diploic space and thinning of the inner and outer tables of the occipital bone. The cyst appeared as isointense to the cerebrospinal fluid on both T1- and T2-weighted images. The differential diagnosis of intradiploic epidermoid cyst could be excluded because the lesion was low intensity on diffusion-weighted MR images. Arachnoid cyst is a benign lesion, so exploratory surgery should be avoided unless the cyst is symptomatic. Diffusion-weighted MR imaging is an effective modality to distinguish diploic epidermoid cysts from arachnoid cysts.