CYSTIC PARATHYROID ADENOMA

Girish M Parmar, et al: Cystic Parathyroid Adenoma in Four Patients from India,

JAFES,  Vol. 27 No. 2 November 2012

 

DISCUSSION

 

Here we describe  4  cases with cystic lesions of the parathyroid gland. Three of these (Cases  1,2  and  3) had parathyroid adenomas with cystic degeneration whereas Case 4 had  a  true parathyroid cyst. Cystic lesions of the parathyroid gland are rare (0.5%–1% of all parathyroid pathologies).  Macroscopic cysts larger than 1 cm in diameter are referred to as parathyroid cysts and necessitate further investigation. Some investigators have suggested that the true prevalence of parathyroid cysts remains uncertain and that these lesions may occur more frequently than is generally appreciated.Cystic lesions of the  parathyroid gland can be  either due to true parathyroid cyst  as seen in Case 4, or due to cystic degeneration of parathyroid adenoma as seen in Cases 1, 2 and 3. Most of the parathyroid gland adenomas are solid while cystic degeneration is seen in 1-2% of patients with primary hyperparathyroidism.

 

Approximately 90% of true parathyroid cysts are classified as nonfunctioning cysts  with normal calcium concentrations  and 10% are functioning cysts  with elevated calcium concentration. However,  in one study, functioning parathyroid cysts were more common. A true parathyroid cyst needs to be differentiated from  a parathyroid adenoma with cystic degeneration. Parathyroid cysts are more frequent in females between 20 to  60 years of age,  whereas parathyroid adenomas are more common after 50 years of age.

 

Patients with true nonfunctional parathyroid cysts present with compressive symptoms. On the other hand, patients with true functional parathyroid cysts  and patients with cystic  parathyroid adenoma  present with signs and symptoms of hypercalcemia. 

 

Parathyroid cysts are of variable sizes, ranging from 1 to 10 cm in greatest dimension, with the average cyst measuring approximately 3 to 5 cm. In 85  - 90% of cases, they are located in the neck and often involve the inferior parathyroid glands. In 5 - 10% of cases they have been detected  at ectopic sites  anywhere from the angle of the mandible to the mediastinum. The mediastinal location of the parathyroid cyst can be ascribed to two factors. First, the cyst may descend into the mediastinum because of  its weight and negative intrathoracic pressure. Second, an aberrant mediastinal parathyroid gland may give rise to the cyst.  

 

 

Degeneration of an existing parathyroid adenoma secondary to hemorrhage into the adenoma, also results in cyst formation. The other different theories proposed are: (1) retention of glandular secretions, (2) persistence of vestigial pharyngobranchial ducts, (3) persistence of Kursteiner's canals, (4) enlargement of a microcyst, or (5) coalescence of the microcysts. None of these theories are

universally applicable, and the processes leading to cyst formation may well differ from one person to the next.

Ultrasonography may reveal a nonspecific cystic structure. Analysis of the aspirate generally reveals elevated PTH level, diagnostic of parathyroid cyst.Nonfunctional parathyroid cysts  have  high  fluid PTH

concentrations, in conjunction with normal serum PTH concentrations.

In functional parathyroid cysts, cystic fluid PTH levels can reach several million pg/ml.PTH levels in the cystic fluid were measured only in the fourth patient. 

 

The histologic distinction between a cystic parathyroid adenoma and the rare functional parathyroid cyst is made by the former having a preponderance of chief cells with multilocular degenerative thick-walled cysts and the latter usually consisting of a unilocular thin-walled cyst. 

 

Treatment strategies for parathyroid cysts include surgical excision or aspiration or injection of sclerosing agents.Surgical treatment seems to be the preferred intervention for functional and symptomatic parathyroid cysts as in our patient. Fine-needle aspiration yields the diagnosis and may be considered the treatment of choice for nonfunctional parathyroid cysts. It  leads  to cystic regression without recurrence.

Several reports in the literature support fine-needle aspiration as a therapeutic modality.  For recurrent  nonfunctional parathyroid cysts, sclerotherapy with use of tetracycline and alcohol has also been described. It has been effective but is associated with the risk of subsequent fibrosis and recurrent laryngeal nerve palsy.If  aspiration cannot be done safely or the cyst recurs  after successful aspiration, surgical excision should be done.

Ultrasound-Guided HIFU Used for Treatment of Breast Fibroadenomas

Ultrasound-Guided HIFU Used for Treatment of Breast Fibroadenomas

  

A new noninvasive therapeutic application using ultrasound-guided, high-intensity focused ultrasound (HIFU) is currently being employed for a specifically localized ablation with no skin damage. The ultrasound waves are focused on a small area where the rise in temperature leads to tissue necrosis. This precision avoids injuring healthy tissues around the lesion.

The echotherapy is a technique that enables clinicians to visualize and simultaneously treat a tumor such as fibroadenoma with no incision or scar.

Theraclion (Paris, France; www.theraclion.com), a specialist in cutting-edge medical technology that develops echotherapy technology that uses HIFU, has received the CE marking approval for the noninvasive treatment of breast fibroadenomas, a first for this indication.

“The CE marking widens the use of our technology in the major area of breast fibroadenoma.

Our technology can now be offered to all women suffering from this pathology in Europe. They can benefit from a noninvasive outpatient treatment without general anesthesia which puts an end to the embarrassment and anxiety triggered by this kind of tumor. Noninvasive focused ultrasound surgery guided by real-time ultrasound imaging is consistent with the logic of developing lesser invasive treatments and a reduction of health costs.

This market authorization in Europe will allow us to grow by creating noninvasive surgery centers based on our resulting echotherapy solution within leading hospitals and clinics. Other tumors beside breast fibroadenomas will be treated in a noninvasive manner in the near future,” said Jean-Yves Burel, CEO of Theraclion.

Fibroadenoma is the most widely spread breast benign tumor, with 10% of women risk developing it in their lifetime. It represents more than half of breast biopsies. This disorder hits women of all ages but is a lot more frequent with women under 30.

Estimates show that 50,000 fibroadenoma tumors are detected each year in France, with 320,000 in Europe and 640,000 in the United States.

“I used the EchoPulse to treat 11 patients during a clinical trial at the American Hospital of Paris from January to October 2012. The results from this technique are encouraging with a 60% volume reduction of fibroadenoma in an average period of six months. EchoPulse could represent an interesting alternative to classical surgery,” added Dr. Marc Abehsera from the medical imaging service at the American Hospital of Paris.

“It is interesting [to be able to] participate in the assessment of echotherapy in breast fibroadenoma in the French trial. We are hoping to participate in a multicenter trial that will measure the effects of this type of treatment in breast cancer,” stated Dr. Edouard Poncelet from the woman imaging service at the Valenciennes Hospital Center).

A clinical trial on 40 patients has shown the efficiency and the excellent tolerance of echotherapy for this type of pathology. Currently, fibroadenomas have been treated in three French centers (Lille Jeanne de Flandres Hospital, the Valenciennes Hospital, and the American Hospital of Paris) and one center in Bulgaria (the University Hospital of Sofia), with considerable volume reductions accompanied by the resolution of symptoms.

EchoPulse, the medical device developed by Theraclion, uses ultrasound imaging as a targeting system and HIFU for tissue necrosis, thereby eliminating the need for patients to undergo a surgical procedure. EchoPulse is unique as it combines in the same device an imaging monitoring and treatment system while remaining compact and mobile. In addition to its ergonomic benefits, it provides excellent image quality, a millimetric accuracy of wave shots, and an integrated cooling system for the patient’s safety. The benefits offered by EchoPulse are beneficial for the patients (non-invasive, scarless, and mobile treatment, conscious sedation) but also for the practitioners (fast, effective, and harmless) and hospital centers (efficient, less hospitalization costs, one device for several pathologies).