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| {{CMG}}; {{AE}} {{Ammu}} | | {{Parathyroid adenoma}} |
| | {{CMG}}{{AE}}{{sali}} |
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| {{SK}} Adenoma of parathyroid gland
| | ==[[Parathyroid adenoma overview|Overview]]== |
| ==Overview== | |
| A parathyroid adenoma is a [[adenoma|benign tumor]] of the [[parathyroid gland]]. Parathyroid adenoma can be associated with overexpression of the ''[[cyclin D1]]'' gene. An elevated concentration of
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| serum calcium and serum parathyroid hormone is diagnostic of parathyroid gland. A specific test for parathyroid adenoma is [[sestamibi parathyroid scintigraphy]], the sestamibi scan. Surgery is the mainstay of treatment for parathyroid cancer.
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| == Pathophysiology==
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| * A parathyroid adenoma is a [[adenoma|benign tumor]] of the [[parathyroid gland]]. It generally causes [[hyperparathyroidism]]; there are very few reports of parathyroid adenomas that were not associated with hyperparathyroidism.<ref name=sekine>{{cite journal |author=Sekine O, Hozumi Y, Takemoto N, Kiyozaki H, Yamada S, Konishi F |title=Parathyroid adenoma without hyperparathyroidism |journal=Japanese Journal of Clinical Oncology |volume=34 |issue=3 |pages=155–8 |date=March 2004 |pmid=15078912 |doi=10.1093/jjco/hyh028}}</ref>
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| * A human being usually has four parathyroid glands located on the back surface of the [[thyroid]] in the neck. The parathyroids secrete [[parathyroid hormone]] (PTH), which increases the concentration of [[calcium]] in the blood by inducing the [[bone]]s to release calcium into the blood and the [[kidney]]s to reabsorb it from the urine. When a parathyroid adenoma causes hyperparathyroidism, more parathyroid hormone is secreted, causing the calcium concentration of the blood to rise, resulting in [[Hypercalcaemia|hypercalcemia]].<ref name=fel>{{cite journal |author=Felsenfeld AJ, Rodríguez M, Aguilera-Tejero E |title=Dynamics of parathyroid hormone secretion in health and secondary hyperparathyroidism |journal=Clinical Journal of the American Society of Nephrology |volume=2 |issue=6 |pages=1283–305 |date=November 2007 |pmid=17942777 |doi=10.2215/CJN.01520407}}</ref>
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| === Genetics ===
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| * Parathyroid adenoma can be associated with overexpression of the [[cyclin D1]] gene.<ref>{{cite journal |author=Hsi ED, Zukerberg LR, Yang WI, Arnold A |title=Cyclin D1/PRAD1 expression in parathyroid adenomas: an immunohistochemical study |journal=The Journal of Clinical Endocrinology and Metabolism |volume=81 |issue=5 |pages=1736–9 |date=May 1996 |pmid=8626826 |doi=10.1210/jcem.81.5.8626826}}</ref>
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| ===Micrographs of Parathyroid Adenoma=== | | ==[[Parathyroid adenoma historical perspective|Historical Perspective]]== |
| <gallery>
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| Image:Adenoma 01.jpg|Intermediate/Low magnification micrograph of parathyroid adenoma. H&E stain. Features: Single cell population forming a single mass. Thin capsule. No adipose tissue. +/-Glandular architecture (which may lead to confusion with thyroid tissue). Normal parathyroid gland with prominent adipose tissue is seen on the right of the image.<ref>Parathyroid adenoma. Wikipedia(2015). https://en.wikipedia.org/wiki/Parathyroid_adenoma Accessed on December 29, 2015</ref>
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| Image:Parathyroid adenoma high mag 02.jpg|High magnification micrograph of a parathyroid adenoma. H&E stain. Features: Single cell population forming a single mass. Thin capsule. No adipose tissue. +/-Glandular architecture (which may lead to confusion with thyroid tissue). Normal parathyroid gland with prominent adipose tissue is seen on the right of the image.<ref>Parathyroid adenoma. Wikipedia(2015). https://en.wikipedia.org/wiki/Parathyroid_adenoma Accessed on December 29, 2015</ref>
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| Image:Parathyroid adenoma histopathology (03).jpg|Histopatholgical image of parathyroid adenoma in a patient with primary hyperparathyroidism. Hematoxylin and eosin stain.<ref>Parathyroid adenoma. Wikipedia(2015). https://en.wikipedia.org/wiki/Parathyroid_adenoma Accessed on December 29, 2015</ref>
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| Image:Parathyroid adenoma histopathology 04.jpg|Histopatholgical image of parathyroid adenoma in a patient with primary hyperparathyroidism. Hematoxylin and eosin stain.<ref>Parathyroid adenoma. Wikipedia(2015). https://en.wikipedia.org/wiki/Parathyroid_adenoma Accessed on December 29, 2015</ref>
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| Image:Parathyroid adenoma histopathology05.jpg|Histopatholgical image of parathyroid adenoma in a patient with primary hyperparathyroidism.<ref>Parathyroid adenoma. Wikipedia(2015). https://en.wikipedia.org/wiki/Parathyroid_adenoma Accessed on December 29, 2015</ref>
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| </gallery>
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| == Risk Factors == | | ==[[Parathyroid adenoma classification|Classification]]== |
| * The following risk factors may increase a person’s chance of developing a parathyroid adenoma:
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| :* [[Multiple endocrine neoplasia type 1]] (MEN 1)<ref>Parathyroid adenoma. Canadian cancer society(2015). http://www.cancer.ca/en/cancer-information/cancer-type/parathyroid/parathyroid-cancer/benign-tumours/?region=on Accessed on December 29, 2015</ref>
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| :* Familial isolated hyperparathyroidism(FIHP)
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| :* [[Hyperparathyroidism]]–jaw tumour (HPT-JT) syndrome
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| :* [[Radiation therapy]] to the head or neck
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| ==Diagnosis== | | ==[[Parathyroid adenoma pathophysiology|Pathophysiology]]== |
| ===Diagnostic Criteria===
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| [[Hyperparathyroidism]] is confirmed by blood tests such as calcium and parathormone levels.<ref>Parathyroid adenoma. Wikipedia(2015). https://en.wikipedia.org/wiki/Parathyroid_adenoma Accessed on December 29, 2015</ref> | |
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| === Symptoms === | | ==[[Parathyroid adenoma causes|Causes]]== |
| * [[Fatigue]]
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| * [[Confusion]]
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| * [[Nausea]]
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| * [[Constipation]]
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| * [[Kidney stones]]
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| * [[Muscle aches]]
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| * [[Bone fracture]]
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| ===CT=== | | ==[[Parathyroid adenoma differential diagnosis|Differentiating Vulvar cancer from other Diseases]]== |
| * CT can be very useful for localising the lesion when the site is not known. Shows increased uptake with agents such as Technetium (Tc) 99m Sestamibi (MIBI) (commonly used agent) and Tc-99m tetrofosmin. The nuclear medicine scan can be fused with the CT scan as a SPECT scan increase diagnostic accuracy.
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| :* In the past CT was more commonly used in the setting of a failed parathyroidectomy for the detection of suspected ectopic glands (often mediastinal) 6. However, in recent years, 4D-CT has emerged as valuable modality especially in the era of minimally invasive parathyroidectomy. This type of surgery requires precise localization with anatomical detail and a confident diagnosis of parathyroid adenoma. 4DCT has been shown to be more sensitive than sonography and scintigraphy for preoperative localisation of parathyroid adenomas.
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| * Enhancement on 4D-CT
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| :* On 4D-CT parathyroid adenomas typically demonstrate intense enhancement on arterial phase, washout of contrast on delayed phase and low attenuation on non-contrast imaging.
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| * Secondary signs include:
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| :* The polar vessel which represents an enlarged feeding artery or draining vein to the hypervascular parathyroid adenoma
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| :* A larger lesion size increases the confidence of diagnosis
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| :* Parathyroid adenomas can also have cystic change
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| ===MRI=== | | ==[[Parathyroid adenoma epidemiology and demographics|Epidemiology and Demographics]]== |
| * MRI is infrequently utilized in initial work up because of lower spatial resolution and artifacts. Adenomas can show variable signal intensity on MRI. Reported signal characteristics include:
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| * T1
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| :* Typically intermediate to low signal
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| :* Subacute haemorrhage can cause high signal intensiy
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| :* Fibrosis or old haemorrhage can cause low signal intensity
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| * T2
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| :* Typically hyperintense
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| :* Subacute haemorrhage can cause high signal intensity
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| :* Fibrosis or old haemorrhage can cause low signal intensity
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| * Since most lesions demonstrate high T2 signal intensity, the addition of contrast for MR scanning does not significantly increase detection.
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| ===Ultrasound=== | | ==[[Parathyroid adenoma risk factors|Risk Factors]]== |
| * Ultrasound is one of most commonly used initial imaging modalities.
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| :* Greyscale
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| ::* Most nodules need to be >1cm to be confidently seen on ultrasound
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| ::* Parathyroid adenomas tend to be homogeneously hypoechoic to the overlying thyroid gland
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| ::* An echogenic thyroid capsule separating the thyroid from the parathyroid may be seen
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| * Doppler ultrasound
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| :* Can commonly show a characteristic extrathyroidal feeding vessel (typically a branch off the inferior thyroidal artery), which enters the parathyroid gland at one of the poles. Internal vascularity is also commonly seen in a peripheral distribution. This feeding artery tends to branch around the periphery of the gland before penetration. This feature can give a characteristic arc or rim of vascularity. The overlying thyroid gland may also show an area of asymmetric hypervascularity that may help to locate an underlying adenoma.
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| ===Other Imaging Findings=== | | ==[[Parathyroid adenoma screening|Screening]]== |
| * A specific test for parathyroid adenoma is sestamibi parathyroid scintigraphy, the sestamibi scan. This [[Nuclear medicine|nuclear imaging technique]] reveals the presence and location of pathological parathyroid tissue.<ref>{{cite journal |author=Goldstein RE, Billheimer D, Martin WH, Richards K |title=Sestamibi scanning and minimally invasive radioguided parathyroidectomy without intraoperative parathyroid hormone measurement |journal=Annals of Surgery |volume=237 |issue=5 |pages=722–30; discussion 730–1 |date=May 2003 |pmid=12724639 |pmc=1514518 |doi=10.1097/01.SLA.0000064362.58751.59}}</ref>
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| ===Imaging Examples of Parathyroid Cancer=== | | ==[[Parathyroid adenoma natural history, complications and prognosis|Natural history, complications and prognosis]]== |
| <gallery>
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| Image:Parathyroid adenoma ultrasound.jpg|Sharply marginated, hypoechogenic lesion at the dorsal lower pole of the left thyroid lobe.<ref name=radio>Image courtesy of Dr Roberto Schubert. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/parathyroid-adenoma-5 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BYSANC]</ref>
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| Image:Tc99m MIBI scintigraphy.jpg|High magnification micrograph of a parathyroid adenoma. H&E stain. Features: Single cell population forming a single mass. Thin capsule. No adipose tissue. +/-Glandular architecture (which may lead to confusion with thyroid tissue). Normal parathyroid gland with prominent adipose tissue is seen on the right of the image<ref name=radio> Image courtesy of Dr Roberto Schubert. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/parathyroid-adenoma-5 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BYSANC]</ref>
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| Image:
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| Parathyroid-adenoma-001.jpg|Parathyroid adenoma<ref name=radio> Image courtesy of Dr Roberto Schubert. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/parathyroid-adenoma-5 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BYSANC]</ref>
| | ==Diagnosis== |
| | | [[Parathyroid adenoma history and symptoms|History and Symptoms]] | [[Parathyroid adenoma physical examination|Physical Examination]] [[Parathyroid adenoma CT|CT]] | [[Parathyroid adenoma MRI|MRI]] | [[Parathyroid adenoma other imaging findings|Other Imaging Findings]] | [[Parathyroid adenoma other diagnostic studies|Other Diagnostic Studies]] |
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| Parathyroid-adenoma-002.jpg|Parathyroid adenoma|<ref name=radio> Image courtesy of Dr Roberto Schubert. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/parathyroid-adenoma-5 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BYSANC]</ref> | |
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| Parathyroid-adenoma-101.jpg|Parathyroid adenoma<ref name=radio> Image courtesy of Dr Roberto Schubert. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/parathyroid-adenoma-5 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BYSANC]</ref>
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| Parathyroid-adenoma-102.jpg|Parathyroid adenoma<ref name=radio> Image courtesy of Dr Roberto Schubert. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/parathyroid-adenoma-5 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BYSANC]</ref> | |
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| Parathyroid-adenoma-103.jpg|Parathyroid adenoma<ref name=radio> Image courtesy of Dr Roberto Schubert. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/parathyroid-adenoma-5 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BYSANC]</ref> | |
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| </gallery>
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| == Treatment ==
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| ===Surgery===
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| * [[Surgery]] is the only cure for parathyroid adenomas.<ref name=ds/> It is successful about 95% of the time. [[Parathyroidectomy]] is the removal of the affected gland(s). The standard of treatment of primary hyperparathyroidism was formerly a surgical technique called bilateral neck exploration, in which the neck was opened on both sides, the parathyroids were identified, and the affected tissue was removed.<ref name=bell>{{cite journal |author=Bellantone R, Raffaelli M, DE Crea C, Traini E, Lombardi CP |title=Minimally-invasive parathyroid surgery |journal=Acta Otorhinolaryngologica Italica |volume=31 |issue=4 |pages=207–15 |date=August 2011 |pmid=22065831 |pmc=3203720}}</ref> By the 1980s, unilateral exploration became more common.<ref name=bell/> Parathyroidectomy can now be performed in a [[Invasiveness of surgical procedures|minimally invasive]] fashion, mainly because imaging techniques can pinpoint the location of the tissue.<ref name=bell/> Minimally invasive techniques include smaller open procedures, radio-guided and video-assisted procedures, and totally [[Endoscopy|endoscopic]] surgery.<ref name=bell/>
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| * Before surgery is attempted, the affected glandular tissue must be located. Though the parathyroid glands are usually located on the back of the thyroid, their position is variable. Some people have one or more parathyroid glands elsewhere in the neck anatomy or in the chest. About 10% of parathyroid adenomas are [[Ectopia (medicine)|ectopic]], located not along the back of the thyroid but elsewhere in the body, sometimes in the [[mediastinum]] of the chest.<ref name=ds>{{cite journal |doi=10.4103/0973-0354.96061 |title=Ectopic parathyroid adenoma |journal=Thyroid Research and Practice |volume=9 |issue=2 |pages=68–70 |year=2012 |last1=Dsouza |first1=Caren |last2=Gopalakrishnan |last3=Bhagavan |first3=KR |last4=Rakesh |first4=K}}</ref> This can make them difficult to locate, so various imaging techniques are used, such as the sestamibi scan, [[single-photon emission computed tomography]] (SPECT), [[Medical ultrasonography|ultrasound]], [[Magnetic resonance imaging|MRI]],<ref name=ds/> and [[X-ray computed tomography|CT]] scans.<ref name=ds/><ref>{{cite journal |author=Zald PB, Hamilton BE, Larsen ML, Cohen JI |title=The role of computed tomography for localization of parathyroid adenomas |journal=The Laryngoscope |volume=118 |issue=8 |pages=1405–10 |date=August 2008 |pmid=18528308 |doi=10.1097/MLG.0b013e318177098c}}</ref>
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| ==References==
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| {{Reflist|2}}
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| [[Category:Disease]]
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| [[Category:Oncology]]
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| [[Category:Endocrine system]]
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| [[Category:Endocrinology]]
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| [[Category:Otolaryngology]]
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| [[Category:Disease]]
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| [[Category:Genetic disorders]]
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| ==Related Chapters==
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| *[[Hyperparathyroidism]]
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