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.     

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.     

Two cases of hyperfunctioning parathyroid cyst

Two cases of parathyroid cyst were experienced. Both cases presented clinical data and symptoms of hyperparathyroidism. Microscopically, one had a thin fibrous wall containing parathyroid adenomatous tissue in the inner surface and the other showed cyst formation without any histological evidence of adenoma or hyperplasia. Most parathyroid cysts are non-functioning. In occasional cases, the cyst may contain a hyperfunctioning adenoma. The hyperfunctioning parathyroid cysts with normal parathyroid tissue are discussed.     

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.     

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.     

PARATHYROID CYSTS

Parathyroid cysts are relatively uncommon. They may be non-functioning or associated with primary hyperparathyroidism. Three patients are presented, including one with a large mediastinal parathyroid cyst, and these cases illustrate the range of pathological and clinical features.     

Parathyroid cysts.

Parathyroid cysts are relatively uncommon. They may be non-functioning or associated with primary hyperparathyroidism. Three patients are presented, including one with a large mediastinal parathyroid cyst, and these cases illustrate the range of pathological and clinical features.     

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.     

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     

Pericardial cysts of the mediastinum

Pericardial cysts are an uncommon benign disease. Their treatment, in the past, was based on excision by thoracotomy or, in selected cases, on percutaneous aspiration. The progress of video-assisted thoracoscopy gave new possibilities, but most surgeons still consider the thoracotomic approach as the treatment of choice. The aim of this study is to report our experience and to discuss the role of different therapeutic procedures in the management of pericardial cysts. Between 1970 and 1996, 24 patients with pericardial cysts were treated at the first Department of Surgery of the University of Rome . Of 24 cysts, six were located in the right cardiophrenic angle, three in the left cardiophrenic angle, two in the subcarenal areas, one in the paracardiac area and one on the posterior mediastinum. Ten patients were asymptomatic. Diagnosis was performed preoperatively only in patients with cysts typically located in the cardiophrenic angle. Twenty-three patients were surgically treated by a standard posterolateral thoracotomy or limited thoracotomy with sparing of muscles. One patient underwent CT-guided transparietal fine-needle aspiration. There were no cases of operative mortality. Morbidity was 12.5% and consisted of retained secretions, moderate hypoxemia and partial atelectasis. All patients were submitted to a long-term follow-up and no cyst recurrences were found. We conclude that excision via thoracotomy is an optimal treatment for pericardial cysts. Limited thoracotomy with sparing muscles offers a good cosmetic result and a rapid functional respiratory recovery. Percutaneous cyst aspiration may be, in selected patients, an attractive alternative to surgery.     

Percutaneous treatment of the liver hydatid cysts under sonographic guidance

This paper is a retrospective study of the first 51 cases of liver hydatid cysts, which underwent a conservative treatment between April 1996-December 2000. There were 28 females and 23 males with a mean age of 40.1 years (7-65), which had 63 liver hydatid cysts. In the right liver lobe were located 46 cysts, in the left liver lobe were located 7 cysts and in 10 cases cysts were located in both liver lobes. In 4 cases a pulmonary hydatidosis was associated. Abdominal ultrasound and CT scan were routinely performed and the cysts were classified in type I and II after Gharbi's classification. All of these 63 cysts were treated by ultrasound guided fine-needle percutaneous puncture with aspiration and instillation of sterile alcohol 95 degrees. Pre and postoperative the patients were treated with mebendazol or albendazol. They were followed-up by ultrasound and CT scan examination in the second day postoperative and monthly. No new cysts were noted during an average follow-up of 14.7 months and maximal cyst diameter decreased with minimum 72%. Two episodes of reversible anaphylaxis were encountered. The mean hospital stay was 3.3 days. In this paper the indications for conservative treatment and preliminary results of this method are discussed.     

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 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.     

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.     

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 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.     

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     

腹腔镜治疗腹腔巨大囊肿及术后下身水肿处理(附5例报告)

目的探讨腹腔镜处理腹腔巨大囊肿及术后下身水肿的方法. 方法 5例腹腔巨大囊肿先行囊肿抽液(1 500～2 000 ml,平均1 800 ml)减压,2例巨大肝囊肿采用经皮穿刺抽液,3例下腹腔囊肿在脐缘小切口直视下抽液,使腹腔空间增大后行腹腔镜下囊肿切除(3例)或开窗引流(2例).对术后出现的下身水肿口服(2例)或静脉注射(3例)利尿剂. 结果 4例术后症状完全消失,1例多囊肝症状明显改善.随访3个月～1年,症状无复发.下身水肿均在5～7 d内基本消失. 结论先行囊肿抽液减压及术后应用小剂量利尿剂可使腹腔巨大囊肿能在腹腔镜下顺利处理并恢复.     

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.