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Parathyroid Adenoma

Parathyroid Gland Adenoma

A parathyroid adenoma is a benign tumor that arises from the parathyroid gland.


Presentation

Symptomatic patients present with manifestations that are reflective of hypercalcemia. Features include lethargy, fatigue, polydipsia, polyuria, myalgia, abdominal pain, constipation, nausea, and emesis. Also, patients may exhibit mental status changes and depression. Complications include nephrolithiasis, osteoporosis, cardiac arrhythmias, coma, and possibly even death.

Weakness
  • Other complications are less common, but may include: Nephrocalcinosis (calcium deposits in the kidneys that can reduce kidney function) Osteitis fibrosa cystica (softened, weak areas in the bones) Complications from surgery include: Damage to a nerve[nlm.nih.gov]
  • Introduction Adenomas of the parathyroid gland typically present with symptoms of hyperparathyroidism, manifested by fatigue, bone pain, abdominal pain, weakness, dyspepsia, nephrolithiasis and skeletal bone disease.[ncbi.nlm.nih.gov]
  • The patient suffered from typical symptoms of hypercalcemia such as weakness, bone disease, and recurrent nephrolithiasis; she had a painless cervical mass for 5 months.[ncbi.nlm.nih.gov]
Fatigue
  • Features include lethargy, fatigue, polydipsia, polyuria, myalgia, abdominal pain, constipation, nausea, and emesis. Also, patients may exhibit mental status changes and depression.[symptoma.com]
  • A 43-year-old woman with no significant medical or family history presented with fatigue and was diagnosed with primary hyperparathyroidism; however, preoperative imaging including sestamibi scan and ultrasound was unable to identify the hyperfunctioning[ncbi.nlm.nih.gov]
  • A 57-year-old man with symptoms of fatigue, joint pains and insomnia was found to have hypercalcaemia secondary to hyperparathyroidism with a corrected calcium of 2.61 mmol/L (2.2-2.6 mmol/L) and a serum parathyroid hormone (PTH) of 86 pg/mL (10-65 pg[ncbi.nlm.nih.gov]
  • Introduction Adenomas of the parathyroid gland typically present with symptoms of hyperparathyroidism, manifested by fatigue, bone pain, abdominal pain, weakness, dyspepsia, nephrolithiasis and skeletal bone disease.[ncbi.nlm.nih.gov]
  • Other non-specific symptoms include depression, muscle weakness, and fatigue. Every effort is made to medically treat or control these conditions prior to surgery.[medicinenet.com]
Thyroid Nodule
  • Parathyroid adenomas may occur within the thyroid, clinically simulating thyroid nodules.[ncbi.nlm.nih.gov]
  • A thyroid nodule was discovered on thyroid ultrasound in a woman with a history of left partial thyroid lobectomy. Fine-needle aspiration cytology revealed a follicular neoplasm comprising oncocytic cells (Hürthle cells).[ncbi.nlm.nih.gov]
  • MORPHOLOGY OF THE PITUITARY 19 THE OPTIC CHIASM IN ENDOCRINOLOGIC 204 PARANEOPLASTIC ENDOCRINE 223 SEX HORMONES AND HUMAN 219 APPROACH TO THE PATIENT WITH 37 ADVERSE EFFECTS OF IODIDE 360 MORPHOLOGY OF THE THYROID 38 NONTOXIC GOITER 366 SYNTHESIS AND 39 THE THYROID[books.google.com]
  • The subsequent ultrasound study could not distinguish between a parathyroid adenoma within or immediately adjacent to, the right lobe of the thyroid and a thyroid nodule.[healio.com]
Weight Loss
  • The patient was a 41-year-old female who presented anorexia, weight loss, polydipsia, polyuria, and constipation, bone pain particularly in the pelvis, lacrimation, and burning sensation of the eyes. She also had repeated urinary infections.[omicsonline.org]
  • Weight loss for no known reason. Being much more thirsty than usual. Urinating much more than usual. Constipation. Trouble thinking clearly.[cancer.gov]
Aspiration
  • Fine-needle aspiration cytology revealed a follicular neoplasm comprising oncocytic cells (Hürthle cells).[ncbi.nlm.nih.gov]
  • In order to obtain the diagnosis and to plan treatment he underwent a full battery of tests (CT, MRI, blood tests, hormonal assays, ultrasounds, thyroid scintigraphy, urine tests and fine-needle aspiration of the mass), but none of these was able to define[ncbi.nlm.nih.gov]
  • Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was used to confirm the diagnosis of parathyroid adenoma and thoracoscopic resection was subsequently performed.[ncbi.nlm.nih.gov]
  • Fine-needle aspiration (FNA) of these presumably "thyroid nodules" can lead to misinterpretation of cytomorphological findings because of similarities in cytological features of parathyroid and thyroid lesions.[ncbi.nlm.nih.gov]
  • Results on thyroid scintigraphy showed hypoactivity, and thyroid fine-needle aspiration cytology process was suggested from the nodule. Simultaneous existence of parathyroid adenoma and thyroid nonmedullary carcinoma is rarely observed.[ncbi.nlm.nih.gov]
Abdominal Pain
  • Features include lethargy, fatigue, polydipsia, polyuria, myalgia, abdominal pain, constipation, nausea, and emesis. Also, patients may exhibit mental status changes and depression.[symptoma.com]
  • Introduction Adenomas of the parathyroid gland typically present with symptoms of hyperparathyroidism, manifested by fatigue, bone pain, abdominal pain, weakness, dyspepsia, nephrolithiasis and skeletal bone disease.[ncbi.nlm.nih.gov]
  • However, patients can experience common symptoms that can range from joint, muscle, and abdominal pain to slight discomfort. Additionally patients might be experiencing feelings of depression due to the hormonal imbalance.[en.wikipedia.org]
  • You have nausea, vomiting, and abdominal pain. You cannot think clearly. When should I contact my healthcare provider? You have bone and joint pain. You have pain in your lower back, side, or stomach.[drugs.com]
  • Symptoms of parathyroid tumor includes aches and pains in the bones, kidney problems, nausea, abdominal pain, vomiting, fatigue, excessive urination, depression, In most cases, we do not know what causes the parathyroid gland to develop a tumor.[larianmd.com]
Epigastric Pain
  • Physical Examination Findings in Persons with Parathyroid Disorders System Finding Possible cause(s) Abdominal Flank pain, tenderness Nephrolithiasis from hypercalcemia Epigastric pain, tenderness Pancreatitis from hypercalcemia, or causing hypocalcemia[aafp.org]
Tenderness in the Epigastric Region
  • Abdominal examination showed mild tenderness in the epigastric region. Other systemic examination was normal. His serum amylase was 290 mg/dL and serum calcium was 11.3 mg/dL.[doi.org]
Retinal Pigmentation
  • The lesion demonstrated overlying focal choroidal atrophy (n 63, 35%) and retinal pigment epithelium atrophy (n 88, 49%). There was no case of subretinal fluid, hemorrhage, or choroidal neovascular membrane.[ncbi.nlm.nih.gov]
Facial Angiofibroma
  • Its clinical presentation includes MEN 1-related tumours such as parathyroid and anterior pituitary tumours in possible association with gonadal, adrenal, renal and thyroid tumours as well as facial angiofibromas, colagenomas and meningiomas.[ncbi.nlm.nih.gov]
Osteoporosis
  • Hormone replacement therapy (HRT) Postmenopausal women may be treated with HRT to prevent osteoporosis. Surgical excision of the adenoma is usually curative in 95% of patients.[symptoma.com]
  • Osteoporosis and the increased risk for bone fractures is the most common concern.[nlm.nih.gov]
  • These efforts include avoiding calcium rich foods, proper hydration, and medications to avoid osteoporosis. As opposed to parathyroid adenoma, it should be noted that parathyroid cancer is very rare.[medicinenet.com]
  • Primary hyperparathyroidism is a common endocrine condition in which one or more of the four parathyroid glands in the neck releases too much parathyroid hormone (PTH). this leads to excess calcium in the blood and if untreated it can cause osteoporosis[clinicaltrials.gov]
  • Bone scan showed patchy tracer uptake in almost entire skeleton with generalised osteoporosis and microfractures, suggestive of metabolic bone disease.[bjmp.org]
Bone Pain
  • A young 18-year-old female patient with general bone pain and history of multiple fractures brought her to our medical attention. Laboratory work showed hypercalcemia and high parathyroid hormone levels in the blood.[ncbi.nlm.nih.gov]
  • We report a case of a 70-year-old man with a history of total parathyroidectomy and thymectomy presented with a lack of appetite, nausea, and generalized bone pain, polydipsia and a calcium level of 14.4 mg/dl. 99mTc-sestamibi scintigraphy with single-photon[ncbi.nlm.nih.gov]
  • Primary hyperparathyroidism should be kept in mind in all patients presenting with history of bone problems ranging from simple bone pain to spontaneous or low trauma fracture associated with hypercalcemia.[ncbi.nlm.nih.gov]
  • We report one such incidence of a 14 years old girl who presented with bone pains short stature, and generalized muscle wasting.[ncbi.nlm.nih.gov]
  • Initially, the patient experienced a sudden onset of gastrointestinal symptoms, polyuria, polydipsia, bone pain, renal dysfunction, nephrolithiasis, and acute pancreatitis, symptoms associated with hypercalcemia. Biochemical findings suggested PHPT.[ncbi.nlm.nih.gov]
Arthralgia
  • […] vision, insomnia, lethargy, weakness Possible diagnoses: corneal calcification, delirium, mild cognitive impairment Renal Polydipsia, polyuria, renal colic Possible diagnoses: nephrocalcinosis, nephrolithiasis, nephrogenic diabetes insipidus Skeletal Arthralgia[aafp.org]
Leg Pain
  • A 17-year-old male patient with a complaint of severe leg pain was admitted to our hospital. Seven months before he had a fracture of his distal humerus after falling on to his left shoulder and was treated conservatively.[ncbi.nlm.nih.gov]
Genu Valgum
  • She was found to have genu valgum at the knee joint, pectus carniatum, scoliosis and cystic changes in pelvis and calvarium. Biochemical investigations and parathyroid Tc-99mMIBI scan confirmed the diagnosis of a parathyroid adenoma.[ncbi.nlm.nih.gov]
Breast Mass
  • We describe a case of a 57-year-old woman who underwent parathyroid scintigraphy and F-FDG PET/CT in the same week due to hyperparathyroidism and an enlarging breast mass, respectively.[ncbi.nlm.nih.gov]
Polyuria
  • Initially, the patient experienced a sudden onset of gastrointestinal symptoms, polyuria, polydipsia, bone pain, renal dysfunction, nephrolithiasis, and acute pancreatitis, symptoms associated with hypercalcemia. Biochemical findings suggested PHPT.[ncbi.nlm.nih.gov]
  • Features include lethargy, fatigue, polydipsia, polyuria, myalgia, abdominal pain, constipation, nausea, and emesis. Also, patients may exhibit mental status changes and depression.[symptoma.com]
  • The patient was a 41-year-old female who presented anorexia, weight loss, polydipsia, polyuria, and constipation, bone pain particularly in the pelvis, lacrimation, and burning sensation of the eyes. She also had repeated urinary infections.[omicsonline.org]
  • The incidence of parathyroid adenoma is reported to be about 85%. [3] The most frequent symptoms are weakness, fatigue, anorexia, nausea, vomiting, polydipsia and polyuria, loss of weight, dyspepsia, constipation, and headaches.[ijpmonline.org]
  • The disease is usually detected with symptoms of hypercalcemia, including urinary calculus, bone lesion (osteoporosis), polyposia and polyuria, general malaise, vomiting, and constipation.[cardiothoracicsurgery.biomedcentral.com]

Workup

The clinical evaluation consists of the individual's history, physical exam, and appropriate studies.

Laboratory tests

Biochemical assessment should include measurements of the serum calcium and PTH levels.

Imaging

Once primary hyperparathyroidism has been demonstrated, imaging is obtained. Specifically, parathyroid ultrasonography is the initial study since it is noninvasive and inexpensive. This is followed by sestamibi parathyroid scintigraphy for detection and confirmation of the adenoma [4]. This scan exhibits a 90% sensitivity for locating the lesion. These studies are also recommended for preoperative planning [5] although other modalities may be utilized as well.

Since 10% of these tumors are ectopic, they can be discovered by the use of computed tomography (CT), magnetic resonance imaging (MRI), scintigraphy, single photon emission computed tomography (SPECT), and/or ultrasonography [6].

Calcium Increased
  • increased Prognosis benign Other depression, psychosis, delirium, coma, ataxia Clin.[librepathology.org]
  • In the responder group, treatment with calcitriol shifted the PTH–calcium curve to the right with a set point of calcium increase from 1.08 0.02 to 1.13 0.02 mM ( P 0.01), and both basal and maximal PTH values decreased ( Table 2 ).[doi.org]
Parathyroid Hormone Increased
  • As a result, your parathyroid glands enlarge and their output of parathyroid hormone increases. The raised levels of parathyroid hormone are appropriate due to the low level of calcium in your blood.[patient.info]
Phosphate Decreased
  • decreased see hyperparathyroidism Technetium-99m-sestamibi radionuclide scan localizes mass Treatment Surgical adenoma excision hungry bones syndrome increased bone breakdown and leads to increased osteoblast activity in response to increased osteoclast[medbullets.com]

Treatment

Surgery

Parathyroidectomy is recommended for symptomatic patients and asymptomatic individuals below the age of 50 [7]. Some experts believe in expanding the criteria further [8].

Historically, bilateral neck exploration was the standard management for identification and excision of the lesion but this was replaced by unilateral exploration a few decades ago [9]. Due to modern advancements in imaging, parathyroidectomy may be minimally invasive [9]. Accurate site identification and intraoperative monitoring of PTH are crucial strategies for minimally invasive surgery [10].

Hormone replacement therapy (HRT)

Postmenopausal women may be treated with HRT to prevent osteoporosis.

Prognosis

Surgical excision of the adenoma is usually curative in 95% of patients.

Etiology

The etiology has not been established although 10% of cases are regarded as inherited. Exposure to radiation is the main risk factor [1].

Epidemiology

Approximately 80% to 85% of primary hyperparathyroidism cases are attributed to parathyroid adenoma. In rare cases, there is a presence of hormone-producing parathyroid adenoma without an increase in serum levels of parathyroid hormone (PTH) and calcium [2].

Sex distribution
Age distribution

Pathophysiology

A parathyroid adenoma can arise from any of the four parathyroid glands. These glands release parathyroid hormone (PTH), which stimulate the release of calcium from bones. Consequently, this tumor will produce excess levels of PTH and calcium in serum [3]. Parathyroid adenoma has a negative impact on bone composition because of an excessive mobilization of calcium from bones.

Histological analysis reveals that the tumor is composed of chief cells which are surrounded by a rim of a normal parathyroid gland.

Prevention

There is no prevention for parathyroid adenoma.

Summary

Parathyroid adenoma, a type of parathyroid proliferative disorder, is the leading cause of primary hyperparathyroidism. The diagnosis is achieved through the patient's history, physical exam, laboratory tests and imaging studies. Surgical excision is the mainstay of therapy.

Patient Information

What is parathyroid adenoma?

This is a benign tumor of the parathyroid gland, which is located behind the thyroid gland. The parathyroid gland normally releases the parathyroid hormone, which increases the calcium levels in the blood. Parathyroid adenoma releases excessive amounts of this hormone.

What are the symptoms?

The symptoms are related to high calcium blood levels, which include:

How is it diagnosed?

Laboratory tests will usually show increased calcium and parathyroid hormone levels. Also, imaging studies of the parathyroid gland are very important to confirm and locate the tumor.

How is it treated?

Surgical removal of the tumor is the main treatment when indicated. It cures 95% of patients.

References

Article

  1. Fjälling M, Hansson G, Hedman I, Ragnhult I, Tisell LE. Radiation-induced parathyroid adenomas and thyroid tumors in rats. Acta Pathologica Microbiologica Scandinavica Series A. 1981;89(6):425-429.
  2. Sekine O, Hozumi Y, Takemoto N, Kiyozaki H, Yamada S, Konishi F. Parathyroid adenoma without hyperparathyroidism. Japanese Journal of Clinical Oncology. 2004;34(3):155-158.
  3. Felsenfeld AJ, Rodríguez M, Aguilera-Tejero E. Dynamics of parathyroid hormone secretion in health and secondary hyperparathyroidism. Clinical Journal of the American Society of Nephrology. 2007;2(6):1283-1305.
  4. Goldstein RE, Billheimer D, Martin WH, Richards K. Sestamibi scanning and minimally invasive radio guided parathyroidectomy without intraoperative parathyroid hormone measurement. Annals of Surgery. 2003; 237(5):722-30; discussion 730-731.
  5. Phillips CD, Shatzkes DR. Imaging of the parathyroid glands. Seminars in Ultrasound, CT and MRI. 2012; 33(2):123-129.
  6. Zald PB, Hamilton BE, Larsen ML, Cohen JI. The role of computed tomography for localization of parathyroid adenomas. Laryngoscope. 2008;118(8):1405-1410.
  7. National Institutes of Health. NIH conference. Diagnosis and management of asymptomatic primary hyperparathyroidism: consensus development conference statement. Annals of Internal Medicine. 1991; 114(7):593-597.
  8. Eigelberger MS, Cheah WK, Ituarte PH, Streja L, Duh QY, Clark OH. The NIH criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism: are they too limited?. Annals of Surgery. 2004; 239(4):528-535.
  9. Bellantone R, Raffaelli M, DE Crea C, Traini E, Lombardi CP. Minimally-invasive parathyroid surgery. Acta Otorhinolaryngologica Italica. 2011;31(4):207-215.
  10. Grant CS, Thompson G, Farley D, van Heerden J. Primary hyperparathyroidism surgical management since the introduction of minimally invasive parathyroidectomy: Mayo Clinic experience. Archives of Surgery. 2005; 140(5):472-8; discussion 478-479.

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Last updated: 2019-07-11 21:15