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.     

Lymphoepithelial Cyst of the Pancreas: A Rare Case Report and Review of Literature

Lymphoepithelial cysts are rare pancreatic lesions of undetermined pathogenesis. The literature on this entity is limited to case reports or small series. We describe a case of 66 year male, incidentally diagnosed as lymphoepithelial cyst of pancreas that was managed by enucleation. This is the first case report of lymphoepithelial cyst from India. An extensive Medline search was carried out for lymphoepithelial cyst of pancreas. Till date less than 100 cases were identified in available literature. All these cases (including our case) were analyzed. This entity has uniform and distinctive clinicopathological features. About half of the reported cases were asymptomatic with most of the lesions diagnosed incidentally. Majority of patients presents with non-specific symptoms making preoperative diagnosis difficult. Lymphoepithelial cyst of the pancreas is a rare benign lesion, which is difficult to diagnose preoperatively. High index of suspicion and preoperative fine needle aspiration cytology may help in making diagnosis and avoiding surgery in asymptomatic patients.     

Spontaneous Retropharyngeal Hematoma of a Parathyroid Cyst: Report of a Case

A 41-year-old woman presented with severe and sudden anterior neck swelling, pain, and dysphagia. Computed tomography (CT) scan and ultrasound of the neck showed a giant mass in the retropharyngeal space, displacing the trachea and esophagus anteriorly. Aspiration cytology was done, following which extensive cervical and chest ecchymosis occurred and her symptoms immediately improved. A repeat CT scan demonstrated that the cervical giant mass had vanished, but there was a residual mass in the left paratracheal space. Exploratory surgery of the neck revealed a parathyroid cyst with severe adhesion to the surrounding tissues. We considered that a ruptured parathyroid cyst had induced massive hemorrhage into the cervical tissues and mediastinum, but that the hemorrhage had been absorbed. Extracapsular hemorrhage from a parathyroid adenoma or cyst is rare, especially from a parathyroid cyst. In fact, to our knowledge, this represents only the third case of symptomatic spontaneous bleeding of a parathyroid cyst. Nevertheless, this entity should still be considered in the differential diagnosis of all rapidly progressing retropharyngeal masses. Received: March 3, 2002 / Accepted: September 3, 2002 Reprint requests to: I. Taniguchi     

A single-institution 25-year review of true parathyroid cysts

Background Parathyroid cysts (PCs) are rare, and their origin is a subject of debate. They have been described as either functional, causing hyperparathyroidism, or non-functional in eucalcaemic patients. Patients and methods We have performed a 25-year departmental review of PCs. Features studied included the clinical presentation and intra-operative findings, and a histological review was performed. Cases of cystic degeneration of parathyroid adenomas and pseudocystic change were excluded. Results Over 25 years, 22,009 thyroidectomies and 2,505 parathyroidectomies were performed in our department. Amongst these, 38 non-functional PCs were documented in 37 patients. The mode of presentation included incidental findings on routine chest x-ray, compressive symptoms or an asymptomatic palpable neck mass. Aspiration was the initial treatment in 14 patients and was curative in 10 of these. Four out of 14 patients underwent surgical procedures for recurrence of the cyst that occurred 6 to 48 months after aspiration. In 27 patients, surgery was performed and all identified PCs were localized in the inferior parathyroid glands. Histologically, the cyst wall consisted in associations of lymphoid, muscular, thymic, salivary, adipose and mesenchymal tissues. Conclusions PCs are rare but should be included within the differential diagnosis of a neck lump. True PCs are non-functional. Pathological and immunohistochemical findings are suggestive of a branchial origin. Fine-needle aspiration may be curative and is diagnostic due to the characteristic appearance of the fluid and high PTH levels on assay.     

Epidermoid cyst of spleen, an unusual cause of massive splenomegaly

Spelenomegaly in a child can present a difficult diagnostic problem. Portal hypertension, leukemia, infection, lipidosis, and lymphoma are the most frequent causes.¹ Epithelial cysts are rare; they compose approximately 10% of the nonparasitic benign cysts of the spleen.² The diagnosis seldom is confirmed preoperatively. Percutaneous aspiration of the cyst and selective abdominal angiography are reported to be of major diagnostic value.^3.9 In one case to be reported, splenic aspiration prior to splenoportography lead to the presumptive preoperative diagnosis.     

Cysts of the parathyroid glands. Apropos of 6 cases

Parathyroid cysts are rare lesions. Pathological examination distinguishes the "true" parathyroid cysts (non functional) most often present and cystic degeneration of a parathyroid adenoma (rare) with clinical or biochemical evidence of hyperparathyroidism. With the increased use of ultrasound and fine needle aspiration biopsies, the diagnosis of these cysts can be confirmed by an elevated parathyroid hormone (PTH) assay. The non-functioning parathyroid cysts can be successfully treated by total aspiration of the cyst fluid. Surgical exploration of all parathyroid glands is the treatment of choice for hyperparathyroidism. The different proposed etiologies for parathyroid cysts are discussed.     

Giant intrathyroidal parathyroid cyst with hyperparathyroidism: a case report

Parathyroid cysts are rare lesions. A correct pre-operative diagnosis is rarely formulated. The Authors report a case of young woman with hyperparathyroidism do to a giant intrathyroidal parathyroid cyst. Aetiology, diagnosis and management are discussed.     

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.     

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.     

无功能性甲状旁腺囊肿：附15例报告

目的 了解无功能性甲状旁腺囊肿的临床特点,探讨其诊治方法.方法 对近16年来收治的无功能性甲状旁腺囊肿15例患者的临床资料进行回顾性分析研究.结果 术前均未获得诊断,均经术后病理检查证实.全组均行手术切除获得治愈,随访无复发.结论 对无功能性甲状旁腺囊肿,病理学检查是最可靠的诊断方法,针刺抽液测定PTH或细胞学检查有助于术前诊断.手术切除是最理想的治疗方法.     

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]

The Authors review the world literature on parathyroid cysts and report a case of this uncommon disease. The importance of an early pre-operative diagnosis by ultrasound, blood calcium level and parathyroid hormone assay with fine needle aspiration biopsy is pointed out. According to several surgeons, only the functioning parathyroid cysts require operation; needle aspiration may be appropriate therapy for the nonfunctioning ones.     

A case of severe rhinophyma (gigantic rhinophyma)

Summary Rhinophyma is classically a benign condition whose etiology and pathogenesis are not well understood. A few cases of giant rhinophymas have been reported in the literature. In this article, a case of gigantic, lobulated rhinophyma is presented. The appearance was unusual, and there was cyst formation histologically.     

Two cases of adrenal cysts

Two cases of adrenal cysts are described. The first case is of bilateral adrenal cysts in a 44-year-old woman. It seems to be the first case of bilateral adrenal cysts in the Japanese literature. The second case is of a left adrenal cyst with sandy calcification in a 71-year-old woman presenting with asymptomatic gross hematuria. Several hormone levels in the cyst fluid were higher than in those in the plasma; cortisol and aldosterone in the first case, and cortisol in the latter. This finding suggests that the hormonal study of cyst fluid obtained by percutaneous needle aspiration under ultrasonic guidance is useful in the differential diagnosis of adrenal cyst from those arising from other organs.     

Risk for laparoscopic fenestration of liver cysts

Background: Laparoscopic fenestration is considered the best treatment for symptomatic simple liver cysts. Conversely, the laparoscopic approach for the management of hydatid simple liver cysts is not widely accepted because of the risk for severe complications. Despite improvement in imaging techniques, the probability of preoperatively mistaking a hydatid liver cyst for a simple liver cyst remains about 5%. Therefore, laparoscopic fenestration, planned for a liver cyst could be performed unintentionally for an undiagnosed hydatid liver cyst. Methods: From January 2000 to January 2001, 15 patients with a diagnosis of liver cyst underwent laparoscopy for fenestration. In all cases preoperative serologic and imaging assessment had excluded hydatid liver cyst. To further exclude hydatid liver cyst, preliminary aspiration of the cyst with assessment of cystic fluid characteristics was performed. Results: In two patients with presumedly simple liver cyst, hydatid liver cyst was diagnosed instead at laparoscopy by aspiration of cystic fluid. The procedure was converted to laparotomy with subtotal pericystectomy. Conclusions: The risk of misdiagnosing a hydatid liver cyst for a simple liver cyst, especially in the presence of a solitary cyst, should be considered before laparoscopic fenestration is performed. Intraoperative aspiration of cyst fluid before fenestration can minimize this risk, thus avoiding severe intraoperative and late complications.     

Mediastinal parathyroid cysts revisited

BACKGROUND: A case of a functioning mediastinal cyst is presented. METHODS: A comprehensive review of the literature found 93 patients in whom a parathyroid cyst or cysts extended into, or was completely contained within, the mediastinum. Including our patient, there were 46 men and 45 women, and the gender was not recorded in three. RESULTS: The cysts were located in the anterosuperior region in 56 patients, in the middle region of the mediastinum in 26, and in the anterior, prevascular region in 12. Thirty-nine patients had functioning cysts associated with hyperparathyroidism of varying severity; seven patients presented with a hypercalcemic crisis. Local symptomatology consisted of a neck mass, respiratory distress, and occasional dysphagia or chest pain. Recurrent laryngeal nerve paresis was present in nine patients, and innominate vein compression or thrombosis was present in two. The cysts in all but four patients were treated by open surgical excision; two were treated by thoracoscopy, and two patients only had fine-needle aspiration of the cyst. The cyst was excised via a cervical approach in 67 patients and by a thoracotomy or median sternotomy or a variation thereof in 23. There was no operative mortality and morbidity was minimal. CONCLUSION: Surgical resection was successful in all and remains the treatment of choice for mediastinal parathyroid cysts.     

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.     

Treatment of a nonfunctioning parathyroid cyst with tetracycline injection

Parathyroid cysts are uncommon: about 200 cases have been reported. They can be functional (i.e., accompanied by signs of primary hyperparathyroidism), or nonfunctional. Preoperative diagnosis is difficult, although it has become increasingly frequent with the use of ultrasound and fine-needle aspiration biopsy. Fluid of parathyroid cysts is almost invariably watery, colorless, and crystal clear, which should cause clinical suspicion. However, definitive diagnosis relies on the demonstration of high parathyroid hormone (PTH) levels in the fluid. Puncture may cure nonfunctioning cysts, but surgery is indicated when the lesion recurs after several fine-needle aspirations. We report a case of a nonfunctioning parathyroid cyst in a 17-year-old boy, which reappeared after two punctures made 6 months apart. On the third occasion, 1 mL of a sterile tetracycline solution injected into the cyst cured the lesion. Tetracycline and other sclerosants have been recommended as a treatment of recurring thyroid cysts. We suggest that injection of a sclerosant should be considered as an alternative to surgery in recurring, nonfunctional cysts of the parathyroid glands.     

Laparoscopic management following ultrasonographic-guided drainage in a patient with giant paraovarian cyst

Background: Giant and paraovarian cysts are unusual masses that are usually treated by laparotomy. The safety of laparoscopic management of benign paraovarian cysts has been demonstrated, but it is believed that the size of benign paraovarian cysts is a limiting factor for laparoscopic surgery. Methods: We describe a new technique for the laparoscopic removal of a giant and benign paraovarian cyst in a 40-year-old woman. A paraovarian cystic mass was detected on the right part of her body that extended to the liver. It was confirmed on both ultrasonography and computed tomography scans. After ultrasound-guided aspiration of the cyst, the mass was resected laparoscopically. Results: No complications were noted during or after the surgical procedure. The patient was discharged on postoperative day 2. Conclusions: Laparoscopic surgery can be safely applied in patients with giant and benign paraovarian cysts.     

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.