Large non-functioning parathyroid cysts: our institutional experience of a rare entity and a possible pitfall in thyroid cytology.

OBJECTIVE: Large non-functioning parathyroid cysts represent a rare entity with a benign clinical course. They may be misdiagnosed as thyroid cystic neoplasms on fine needle aspiration cytology (FNAC), resulting in inappropriate surgical treatment. We evaluated our institutional experience in the diagnosis of large parathyroid cystic lesions underlining all the differential diagnoses and pitfalls. METHODS: In the period between 1998 and 2012, we reported the cytology of eight large (>2.5 cm) parathyroid cystic lesions (all female patients) with histological control. The aspirations were performed with a 25-gauge needle with ultrasonographic guidance. The aspirated material was processed with liquid-based cytology (LBC). All the patients had normal serum parathyroid hormone (PTH) and calcium. RESULTS: The cytological samples showed a fluid watery component without colloid and few or absent epithelial cells. The resulting negativity for thyroglobulin and positivity for PTH, carried out on the cystic fluids, suggested parathyroid lesions rather than either thyroid cystic lesions (including follicular thyroid neoplasm) or cystic malignant lesions. All the patients underwent surgery without complications. CONCLUSIONS: To the best of our knowledge, this is one of the largest series with cytohistological evaluation of large parathyroid cysts. The incidence of large parathyroid cysts remains controversial as most patients are asymptomatic. FNAC may be performed with conclusive results in the majority of cystic cases. The detection of PTH and calcium on the cystic liquid is likely to achieve a correct cytological diagnosis, allowing adequate treatment and ruling out a more frequent thyroid lesion.

Is there a role for video-assisted parathyroidectomy in regions with high prevalence of goitre?

Minimally-invasive procedures for parathyroidectomy have revolutionized the surgical treatment of primary hyperparathyroidism (pHPT). Coexistence of goitre is considered a major contraindication for these approaches, especially if unilateral. A specific advantage of video-assisted parathyroidectomy (VAP) compared to other endoscopic techniques is the possibility to combine it with thyroidectomy when necessary and when the selection criteria for video-assisted thyroidectomy (VAT) are met. We evaluated the role of VAP in a region with a high prevalence of goitre. The medical records of all patients who underwent parathyroidectomy and concomitant thyroid resection in our Division, between May 1998 and June 2012, were reviewed. Patients who underwent VAP and concomitant VAT were included in this study. Overall, in this period, 615 patients were treated in our Division for pHPT and 227 patients (36.9%) underwent concomitant thyroid resection. Among these, 384 patients were selected for VAP and 124 (32.3%) underwent concomitant VAT (lobectomy in 26 cases, total thyroidectomy in 98). No conversion to conventional surgery was registered. Mean operative time was 66.6 ± 43.6 min. Transient hypocalcaemia was observed in 42 cases. A transient recurrent nerve lesion was registered in one case. No other complications occurred. Final histology showed parathyroid adenoma in all but two cases of parathyroid carcinoma, benign goitre in 119 cases and papillary thyroid carcinoma in the remaining 5 patients. After a mean follow-up of 33.2 months, no persistent or recurrent disease was observed. In our experience, a video-assisted approach for the treatment of synchronous thyroid and parathyroid diseases is feasible, effective and safe at least considering short-term follow-up.

Radioguided parathyroidectomy in forearm graft for recurrent hyperparathyroidism.

We report a peculiar case of recurrent hyperparathyroidism caused by hyperplasia of a forearm graft implanted following a total parathyroidectomy in a 38-year-old patient with chronic renal failure. The forearm graft hyperplasia was detected using (99)Tc(m)-sestamibi scanning, which identified hyperplastic transplanted parathyroid tissue in the forearm of the patient. During the initial surgery, the surgeon failed to mark the parathyroid tissue with sutures or clips to facilitate locating it. Therefore, we referred the patient for radioguided surgery. This surgical procedure allowed us to locate and completely remove the hyperfunctioning transplanted parathyroid tissue.

A less invasive, selective, functional neck dissection for papillary thyroid carcinoma.

HYPOTHESIS: To describe an alternative lateral neck access in order to perform neck dissection in papillary thyroid carcinoma (PTC) with lymph node involvement. DESIGN: Prospective (January 2000 to December 2003), 36-month study. SETTING: Catholic University of Rome and University of "Tor Vergata", Rome, Italy. PATIENTS AND METHODS: Twenty-four consecutive patients with PTC and cervical lymph node metastases were included. Functional neck dissection (FND), unilateral or bilateral, was performed acceding via a lateral dissection through a traditional Kocher incision, running along the superficial fascia of the neck and posteriorly to the sternocleidomastoideus muscle. RESULTS: Mean age was 39.04+/-13.69 years. Twenty patients were women and four were men. Mean tumour size was 2.5+/-1 cm, while the greatest metastatic lymph node size was 4.5 cm. Minimally invasive, selective FND was performed in all patients associated to total thyroidectomy and central compartment lymph node clearance. Metastatic lymph nodes were found in 142 out of 340 of the lymph nodes dissected. CONCLUSIONS: Minimally invasive neck dissection seems to carry a lower risk in terms of specific morbidity and allows a quicker recovery and a better aesthetic result. This access has to be considered as a less invasive procedure compared to the other surgical accesses for the radical or modified lateral neck dissection.

[Differentiated tumor of the thyroid in children and adolescents]. / Tumore differenziato della tiroide nel bambino e nell'adolescente.

Differentiated thyroid carcinoma (DTC) is rare in young patients and represents 0,5 to 3,0% of childhood carcinomas. The incidence increases with age: a peak incidence is observed between 15 and 19 years of age. DTC in children is frequently associated with greater risk of cervical lymph node involvement (60-80% of cases) and lung metastases at diagnosis in 20% of patients. However the prognosis for these patients is better when compared with that of adults, despite a high incidence of relapse, leading to reoperation. Young age (<16 years), lymph node involvement or distant metastases at diagnosis and some histopathologic characteristics have been suggested as predictive factors of recurrences. The records of 33 patients with DTC in a 14-year period (1990-2004) were reviewed. There were 31 females and 2 males who ranged from 11 to 21 years. At the diagnosis 15 patients had disease confined to the thyroid, 18 had additional lymph node metastases in the neck; one of them had also lung metastases. Total thyroidectomy (TT) was the elective approach in all patients (4 cases videoassisted). TT was associated to functional neck dissection in 21 cases. 131I was administrated to 28 patients (3,7 GBq as ablative dose): 11 of this received further radioiodine treatments (mean 7,4 GBq) because of elevated serum thyroglobulin levels and presence of loco-regional or lung metastasis at diagnostic total body scan after 131I treatment. The overall survival rate was 100% at a follow up of 4 months to 14 years.