Advertisement

The Significance of Histologically “Large Normal” Parathyroid Glands in Primary Hyperparathyroidism

  • Russel KrawitzEmail author
  • Anthony Glover
  • Sireesha Koneru
  • James Jiang
  • Aimee Di Marco
  • Anthony J. Gill
  • Ahmad Aniss
  • Mark Sywak
  • Leigh Delbridge
  • Stan Sidhu
Original Scientific Report

Abstract

Introduction

We investigated outcomes in a cohort of patients with a biochemical diagnosis of primary hyperparathyroidism (pHPT) undergoing surgery for asymptomatic disease or target organ damage, where a focussed or four-gland operation was undertaken and the histopathology only reported a “large normal” parathyroid gland (LNP).

Methods and materials

Patients subjected to a parathyroidectomy for pHPT between 2012 and 2018 with a pathology of LNP were included. Patients with fat depletion or additional histological features of adenoma or hyperplasia in any of the resected glands were excluded. A control group was formed from 50 consecutive patients with the histological finding of adenoma or hyperplasia during the same study period. The primary outcome was biochemical normalisation of pHPT at 1–2 weeks and after 6 months post-operatively.

Results

Forty-eight LNP patients (2% of all parathyroidectomies) were included in the study group with 50 matched controls. LNP patients had a lower biochemical cure rate (81% vs. 98% P < 0.05) and a higher risk of recurrence (10% vs. 0%, P = 0.06). LNP patients had a milder form of pHPT (Ca2+ 2.63 vs. 2.68 P < 0.05) with a smaller PTH and Ca2+ drop post-operatively. For LNP patients with failure, a definite additional cause of pHPT was found in only two patients.

Conclusion

This study highlights a controversial area in pHPT and reports LNP as a cause of pHPT. The biochemical analysis of this LNP group supports a benefit in resection in the setting of pHPT, although the risk of failure (persistence/recurrence) is higher than those with adenoma or hyperplasia. Stricter post-operative follow-up of LNP patients should be considered.

Notes

Compliance with ethical standards

Conflict of interest

There were no conflicts of interest declared by any of the authors.

Ethical approval

The study was approved by the relevant Human Research Ethics Committee.

References

  1. 1.
    Herrera M, Gamboa-Dominguez A (2016) Parathyroid embryology, anatomy, and pathology. In: Clark O (ed) Textbook of endocrine surgery, 3rd edn. Bengaluru, Jaypee Brothers Medical Publishers Ltd, pp 627–635Google Scholar
  2. 2.
    Delellis R (2018) Surgical pathology of the parathyroid glands. In: Randolph GW (Ed) Surgery of the thyroid and parathyroid glands, 2nd edn. Elsevier Inc., Amsterdam, pp 673–680e1.  https://doi.org/10.1016/B978-1-4377-2227-7.00070-8 CrossRefGoogle Scholar
  3. 3.
    Norlén O, Wang KC, Tay YK et al (2015) No need to abandon focused parathyroidectomy: a multicenter study of long-term outcome after surgery for primary hyperparathyroidism. Ann Surg 261(5):991–996.  https://doi.org/10.1097/SLA.0000000000000715 CrossRefPubMedGoogle Scholar
  4. 4.
    Milas Z, Milas M (2016) Normocalcemic hyperparathyroidism. In: Clark O (ed) Textbook of endocrine surgery, 3rd edn. Jaypee Brothers Medical Publishers Ltd, Bengaluru, pp 697–703CrossRefGoogle Scholar
  5. 5.
    Wade TJ, Yen TWF, Amin AL, Wang TS (2012) Surgical management of normocalcemic primary hyperparathyroidism. World J Surg 36(4):761–766.  https://doi.org/10.1007/s00268-012-1438-y CrossRefPubMedGoogle Scholar
  6. 6.
    Schneider DF, Burke JF, Ojomo KA et al (2013) Multigland disease and slower decline in intraoperative PTH characterize mild primary hyperparathyroidism. Ann Surg Oncol.  https://doi.org/10.1245/s10434-013-3190-4 CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Black W, Haff R (1970) The surgical pathology of parathyroid chief cell hyperplasia. Am J Clin Pathol 53:565–579CrossRefGoogle Scholar
  8. 8.
    Gill AJ (2014) Understanding the genetic basis of parathyroid carcinoma. Endocr Pathol 25(1):30–34.  https://doi.org/10.1007/s12022-013-9294-3 CrossRefPubMedGoogle Scholar
  9. 9.
    Gill AJ, Lim G, Cheung VKY et al (2019) Parafibromin-deficient (HPT-JT type, CDC73 mutated) parathyroid tumors demonstrate distinctive morphologic features. Am J Surg Pathol.  https://doi.org/10.1097/PAS.0000000000001017 CrossRefPubMedGoogle Scholar
  10. 10.
    Carter JM, Landry A, Hinni M (2012) Lipohyperplasia of the parathyroid glands. Ear Nose Throat J 91(10):441–443CrossRefGoogle Scholar
  11. 11.
    Gómez-ramírez J, Mihai R (2017) Normocalcemic primary hyperparathyroidism: a diagnostic and therapeutic algorithm. Langenbeck’s Arch Surg.  https://doi.org/10.1007/s00423-017-1617-2 CrossRefGoogle Scholar
  12. 12.
    Cetani F, Pardi E, Borsari S, Marcocci C (2011) Molecular pathogenesis of primary hyperparathyroidism. J Endocrinol Investig 34:35–39Google Scholar
  13. 13.
    Kruijff S, Sidhu SB, Sywak MS, Sci M, Gill AJ, Delbridge LW (2014) Negative parafibromin staining predicts malignant behavior in atypical parathyroid adenomas. Ann Surg Oncol.  https://doi.org/10.1245/s10434-013-3288-8 CrossRefPubMedGoogle Scholar
  14. 14.
    Suliburk JW, Sywak MS, Sidhu SB, Delbridge LW (2011) 1000 minimally invasive parathyroidectomies without intra-operative parathyroid hormone measurement: lessons learned. ANZ J Surg 81:362–365.  https://doi.org/10.1111/j.1445-2197.2010.05488.x CrossRefPubMedGoogle Scholar
  15. 15.
    Lavryk OA, Siperstein AE (2017) Use of calcium and parathyroid hormone nomogram to distinguish between atypical primary hyperparathyroidism and normal patients. World J Surg 41(1):122–128.  https://doi.org/10.1007/s00268-016-3716-6 CrossRefPubMedGoogle Scholar
  16. 16.
    Kamycheva E, Sundsfjord J, Jorde R (2004) Serum parathyroid hormone level is associated with body mass index. The 5th Tromso study. Eur J Endocrinol 151(2):167–172.  https://doi.org/10.1530/eje.0.1510167 CrossRefPubMedGoogle Scholar
  17. 17.
    Cham S, Sepahdari AR, Hall KE, Yeh MW, Harari A (2015) Dynamic Parathyroid Computed Tomography (4DCT) facilitates reoperative parathyroidectomy and enables cure of missed hyperplasia. Ann Surg Oncol.  https://doi.org/10.1245/s10434-014-4331-0 CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Russel Krawitz
    • 1
    Email author
  • Anthony Glover
    • 1
    • 2
  • Sireesha Koneru
    • 1
  • James Jiang
    • 1
  • Aimee Di Marco
    • 1
  • Anthony J. Gill
    • 1
    • 2
    • 3
    • 4
  • Ahmad Aniss
    • 1
  • Mark Sywak
    • 1
    • 2
  • Leigh Delbridge
    • 1
    • 2
  • Stan Sidhu
    • 1
    • 2
  1. 1.University of Sydney Endocrine Surgical UnitRoyal North Shore Hospital, Northern Sydney Local Health DistrictSydneyAustralia
  2. 2.Northern Clinical School, Sydney Medical School, Faculty of Medicine and HealthUniversity of SydneySydneyAustralia
  3. 3.NSW Health Pathology, Department of Anatomical PathologyRoyal North Shore HospitalSt LeonardsAustralia
  4. 4.Cancer Diagnosis and Pathology Group, Kolling Institute of Medical ResearchRoyal North Shore HospitalSt LeonardsAustralia

Personalised recommendations