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.     

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.     

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 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     

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.     

Management problems in coexisting parathyroid crisis and florid thyrotoxicosis

The etiologic relationship between parathyroid and thyroid disease is controversial and still not well defined. An increased incidence of parathyroid adenomas with thyroid disease has been suggested by some researchers. Other authors are unable to confirm this and maintain that the major factor contributing to the coexistence of parathyroid adenomas and thyroid disease is the prevalence of these conditions, independently, in middle-aged women. Serum parathyroid hormone levels are generally lower in patients with thyrotoxicosis and higher in patients with hypothyroidism. The simultaneous occurrence of thyrotoxicosis and symptomatic hyperparathyroid crisis has been reported previously only once in the American literature. We report a case of a 32-year-old woman with documented uncontrolled Graves' disease (T4 = 20 micrograms/dl [normal = 4.5 to 11.5 micrograms/dl], total T3 = 361 ng/dl [normal = 115 to 190 ng/dl], T3RU = 53% [normal = 35% to 45%]), who developed parathyroid crisis (serum calcium = 15 mg/dl [normal = 9 to 11 mg/dl], N-terminal parathyroid hormone = 121 pg/ml [normal = 11 to 24 pg/ml], C-terminal parathyroid hormone = 9416 pg/ml [normal = 60 to 450 pg/ml]). After a turbulent 10-day period to achieve a euthyroid state with propranolol, propylthiouracil, and a saturated solution of potassium iodide, operation revealed a large parathyroid adenoma (2 by 2 by 3 cm) and a diffusely hyperplastic thyroid gland. Adenoma excision and bilateral subtotal thyroidectomy were performed. This case illustrates management guidelines of a true endocrine emergency in which prompt operation for acute hyperparathyroidism could not be undertaken until a euthyroid state and reduction in serum calcium levels were achieved with aggressive medical management.     

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.     

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     

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 cytology: avoiding diagnostic pitfalls

BACKGROUND: Interpretation of parathyroid fine-needle aspirates (FNA) remains problematic not only because this type of specimen is rare but also because the pertinent literature is very limited. We systematically reviewed parathyroid FNAs in our files and sought to delineate additional diagnostic criteria. DESIGN: Review of all thyroid and parathyroid aspirates from January 1990 to June 1998 disclosed 12 parathyroid lesions. The final diagnoses included four parathyroid adenomas, one intrathyroidal hyperplastic parathyroid, one intrathyroidal parathyroid adenoma, one atypical parathyroid adenoma (all confirmed by histologic screening or immunocytochemistry), and five parathyroid cysts (all confirmed by immunoassay). Papanicolaou and Diff Quik-stained smears of the parathyroid FNAs were reviewed. The cytologic features were compared and contrasted with those of thyroid FNAs to establish criteria for differential diagnoses. RESULTS: The FNAs of the five parathyroid cysts yielded virtually acellular fluid with a characteristic water-clear appearance and markedly elevated levels of parathyroid hormone. The remaining seven aspirates consisted of moderately cellular smears that showed an admixture of architectural features. Common patterns included cohesive three-dimensional groups, disorganized sheets, papillary fragments, microfollicles, and a single case showing lymphoidlike smears. Although the cells were generally small and round to oval, all cases demonstrated mild to moderate anisokaryosis. The nuclei were hyperchromatic E with coarsely granular chromatin reminiscent of that of small lymphocytes. Occasional nucleoli were noted. Although the cytoplasm was usually pale blue and finely granular with ill-defined borders, two cases showed well-delineated cytoplasmic membranes. Less common findings included cytoplasmic granulation, vacuolization, and rare oxyphilic cells. Naked nuclei were noted in the background of all of the aspirates to varying degrees. Other background findings included the presence of colloidlike material, macrophages, and lymphocytes. One interesting finding that to date has not been reported is the presence of nuclear overlapping (100%) and nuclear molding (71%), which is an uncommon finding in thyroid aspirates. CONCLUSIONS: FNAs of the parathyroid can be easily confused with that of the thyroid, not only because of the clinical similarity between these two types of lesions but also because of the overlap in cytomorphologic features of the aspirated cells. Although no one single cytomorphologic feature is diagnostic, a combination of cytologic parameters noted earlier should raise the possibility of a parathyroid lesion. Aspirates of parathyroid cysts show acellular water-clear fluid with elevated parathyroid hormone measurements.     

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 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.     

Water-Clear Cell Parathyroid Adenoma Causing Primary Hyperparathyroidism in a Patient with Neurofibromatosis Type 1: Report of a Case

Water-clear cell parathyroid adenoma is an exceedingly rare tumor, composed exclusively of tumor cells with abundant foamy cytoplasm. A combination of hyperparathyroidism and neurofibromatosis type 1 (NF1) is also a rare phenomenon. We report an 18-year-old woman with primary hyperparathyroidism caused by water-clear cell parathyroid adenoma in association with NF1. She had renal stones, hypercalcemia, and an elevated plasma level of intact parathyroid hormone. Physical examination revealed a palpable tumor in the right neck, and café-au-lait spots distributed over her entire body. An ultrasound examination showed an isoechoic mass in the right thyroid lobe. Thallium–technetium subtraction scintigraphy showed high thallium accumulation in the right thyroid lobe area. A surgical exploration revealed the palpable mass to be a parathyroid tumor. The pathological features were consistent with water-clear parathyroid adenoma. This is the first reported case of water-clear cell parathyroid adenoma associated with NF1.     

Parathyroid carcinoma: biochemical and pathologic response to DTIC

Parathyroid carcinoma is a rare cause of hyperparathyroidism. Cure results from successful en bloc resection. However, because of its rarity, the malignant nature may not be appreciated at the initial operative procedure and as a result, definitive resection may not be accomplished. However, even with extensive en bloc resections, local recurrences do occur and patients die of metabolic derangements associated with hypercalcemia. Thus in addition to operative intervention, palliative chemotherapy may be required to control the hypercalcemia. Radiotherapy has been unsuccessful. A single case of nonfunctioning parathyroid carcinoma responding to treatment with methotrexate, Adriamycin, cyclophosphamide, and CCNU has been reported. We report a case of recurrent functioning parathyroid carcinoma treated with dacarbazine (DTIC) in which biochemical and pathologic evidence of at least a partial response was seen. The patient, a 33-year-old woman, had undergone five previous neck explorations during a 26-month period for aggressive locally recurrent disease. Before DTIC therapy the intact parathyroid hormone (PTH) level was 1032 pg Eq/ml (normal 163 to 347 pg Eq/ml) and the serum calcium level was 16.8 mg/dl (normal 8.8 to 10.0 mg/dl). After a course of DTIC there was a marked improvement in her clinical status and biochemical parameters (intact PTH 545 pg Eq/ml; serum calcium 11.8 mg/dl). For 2 months her condition stabilized, with PTH levels between 700 and 760 pg Eq/ml and serum calcium levels between 10.2 and 16.0 mg/dl. With a slowly progressive rise in biochemical parameters a second course of DTIC was initiated and a marked drop in serum calcium levels (5.7 mg/dl) occurred, but PTH levels remained unchanged. A progressive course of septicemia, malnutrition, and disseminated intravascular clotting ultimately lead to her death 4 weeks later. At autopsy examination the tumor was confined to the neck. Grossly and microscopically there was extensive central as well as peripheral necrosis of the tumor, which was thought to be the result of the cytotoxic effect of DTIC. From this experience and because of the grim prognosis in patients with recurring parathyroid carcinoma, it may be that aggressive use of chemotherapy with DTIC early in the course of treatment should be considered.     

Intraoperative Parathyroid Aspiration and Parathyroid Hormone Assay as an Alternative to Frozen Section for Tissue Identification

Most people would agree that successful parathyroidectomy depends on two important variables: the surgeon's recognition and excision of the abnormal parathyroid gland(s) and the pathologist's confirmation that the removed tissue is parathyroid tissue. Frozen section is usually employed to confirm the identity of parathyroid tissue, but occasionally confirmation cannot be made without a permanent section, as with intrathyroidal glands. This study proposes a new method of expeditious and easy confirmation of parathyroid tissue utilizing the immunoassay for quick measurement of intraoperative parathyroid hormone (IOPTH). By directly aspirating the suspected adenoma, the assay becomes a rapid diagnostic tool that can be used as an alternative to frozen section. In cases where the surgeon is already planning to employ the assay, the elimination of frozen section is cost-effective. Intraoperative aspiration of histologically confirmed parathyroid adenomas was performed on 12 consecutive patients undergoing parathyroid surgery. Parathyroid glands were aspirated with a 22-gauge syringe after gland excision. Aspirates were placed in 1 to 3 ml of buffered saline. A similar process was performed on 12 thyroid controls. Specimens were centrifuged, aliquotted, and stored at −70°C. The parathyroid hormone value was analyzed electively by rapid assay and the values recorded. For all parathyroid aspirates, the rapid assay value was > 1500 pg/ml, exceeding the uppermost limit of the diagnostic chart. Values for thyroid aspirates ranged from 58 to 85 pg/ml (mean 75.7 pg/ml). In all cases tissue confirmation was achieved with permanent section. Values were 100% sensitive and specific. Measurement of PTH from intraoperative aspiration of suspected parathyroid adenomas is clinically useful in patients for whom frozen section would routinely be employed. Values > 1500 pg/ml secure the tissue diagnosis. There is no additional cost in cases where IOPTH monitoring is already being utilized to confirm cure. The elimination of frozen section could be cost-effective and, for some institutions, actually decrease the operating time as the IOPTH assay takes only 15 minutes. PTH assay is an accurate diagnostic technique and to date is 100% sensitive and specific for differentiating between parathyroid tumors and thyroid nodules.     

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.     

Diagnosis and treatment of cystic disease of the thyroid by aspiration

One hundred forty-one cases of euthyroid solitary "cold" and "uniform" nodules, each of which contained at least 3 ml of fluid obtained on aspiration, are presented. Sixty-three patients had complete disappearance of swelling after one aspiration. Seventy-eight patients were selected for surgery on the basis of cytologic findings of malignancy in the aspirated fluid (one patient), on the basis of recurrent cyst formation after one aspiration (17 patients; in these cases the incidence of malignancy was similar to that in solid, cold nodules), and on the basis of palpable tissue after aspiration that indicated a partially cystic lesion (60 patients). Surgicopathologic findings revealed six malignant lesions; all of these nodules were more than 3 cm in diameter. In percentage, 6.6% of the partially cystic and 2.5% of the purely cystic nodules were malignant. The color of the aspirated fluid did not add to the discriminant value of the aspirate. The identification of malignant conditions in thyroid cysts was handicapped by the yield of acellular material in three of five cases of malignant disease and in more than 50% of benign lesions. However, the study suggests that aspiration biopsy of cystic thyroid nodules when used in association with the above clinical criteria is a useful technique of selecting patients for operation and, by itself, is a safe and reliable means of treating the disorder.     

Follow-up of patients with aspirated breast cysts is necessary

A review was conducted of 401 women who presented with breast lumps that proved to be cysts by yielding fluid on aspiration. The aim was to determine the proportion of patients with cancers that masqueraded as cysts and to establish whether short-term follow-up was necessary. After the first visit, six patients had biopsies because of a residual mass or a bloodstained aspirate. Of these patients, two were found to have cancer. After the follow-up visit, 20 further biopsies were carried out for presence of a mass, bloodstained fluid, or recurrent fluid, and two more cancers were diagnosed. Of the four patients with malignancy, only one had an intracystic carcinoma, two had necrotic grade 3 ductal carcinomas, and one had a malignant phyllode tumor. These findings underline the value of a single return visit after cyst aspiration.     

Parathyroid carcinoma: the Lahey Clinic experience

From 1942 to 1984, 301 operations were performed for hyperparathyroidism; nine patients (3%) had carcinoma. The mean serum calcium level of the patients with carcinoma was 14.0 mg/dl, whereas the mean serum calcium level of patients with benign hyperparathyroidism was 12.0 mg/dl. With follow-up ranging from 2 to 16 years, there has been one death 9 years after the initial operation caused by primary lung cancer. At autopsy the patient also had a recurrence of parathyroid carcinoma in the neck. There were no additional recurrences or deaths. Prognosis was not correlated with any laboratory or pathologic findings. The importance of intraoperative recognition at the time of the initial operation is stressed. En bloc resection is recommended, including ipsilateral thyroid lobectomy and dissection of the tracheoesophageal groove. Radical neck dissection is performed only for extensive cervical node metastases or for reoperations where scarring prevents accurate delineation of the extent of the tumor.     

Aspiration of breast cysts

One hundred and sixty nine women with 220 breast cysts were treated by needle aspiration between 1950 and 1980. Mean follow up was seven years. One hundred and twenty two (72%) patients were aged from 40 to 49 years. The majority (61%) of cysts occurred in the left breast. In 147 patients 174 (79%) of 220 cysts were aspirated once and did not recur at that site. One hundred and eleven (66%) patients presented with a single cyst and had no recurrence in either breast after aspiration. Two patients developed carcinoma of the opposite breast at 8 and 12 years after cyst aspiration. Needle aspiration of the breast is regarded as a safe, simple and economic diagnostic and therapeutic modality in women presenting with single breast lumps.