Wirowski D, Wicke C, Böhner H, Lammers B J, Pohl P, Schwarz K, Goretzki P E
Department of Surgery, Lukaskrankenhaus Neuss, Neuss, Germany.
Exp Clin Endocrinol Diabetes. 2008 Aug;116(8):501-6. doi: 10.1055/s-2008-1058084. Epub 2008 Apr 1.
Cystic lesions of the parathyroid glands are uncommon, and rare are those that cause primary hyperparathyroidism. Preoperative diagnosis can be challenging and some of these tumors might be misinterpreted as parathyroid carcinoma. With an expertise of more than 1700 patients operated on primary hyperparathyroidism, we present six cases with cystic degeneration of a parathyroid gland causing primary hyperparathyroidism in five patients.
A woman at the age of 67 presented with hypercalcaemic crisis due to persistent primary hyperparathyroidism after an operation four years ago. As cervical exploration was unsuccessful, sternotomy was performed and a cystic adenoma of a parathyroid gland could be resected from the anterior mediastinum. The second patient - a 63-year-old female with severe hypercalcaemic crisis, operated on under suspicion of a parathyroid carcinoma - had a functional cyst of the parathyroid gland with a parathyroid hormone level of 700,000 pg/ml in the aspirated fluid. Third, operation on a 70-year-old woman with a benign euthyreot goiter and the laboratory findings of primary hyperparathyroidism revealed a cystic adenoma adjacent to the thyroid gland, whose aspirate had a parathyroid hormone level of 1,500,000 pg/ml. In the fourth case of a 67-year-old female with an adenoma of the right inferior parathyroid gland localized by ultrasonography, the cystic parathyroid adenoma was operated on by video-assistance. A cystic structure in the upper mediastinum was diagnosed in the fifth patient, a 66-year-old woman. It was suspected to be a thyroid cyst at the left-lower pole of the thyroid gland. After hemithyroidectomy pathological evaluation revealed a large parathyroid cyst. The last case of a 56-year-old male illustrates the extensive preoperative work-up of a patient with primary hyperparathyroidism who was preoperatively diagnosed as having a thyroid cyst. Final histopathological examination exposed multiple gland disease with a parathyroid adenoma as well as a cystic parathyroid gland.
Cystic adenomas of the parathyroid glands are often misdiagnosed as thyroid cysts or - in the case of extremely elevated parathyroid hormone levels - even as parathyroid carcinoma. The routine preoperative diagnostic tools, such as ultrasonography or (99m)Tc-sestamibi-scintigraphy, cannot clearly distinguish between these entities and might be jeopardized by mediastinal localization, which is not uncommon in parathyroid adenomas with cystic degeneration.
甲状旁腺的囊性病变并不常见，而导致原发性甲状旁腺功能亢进的病变则更为罕见。术前诊断具有挑战性，其中一些肿瘤可能被误诊为甲状旁腺癌。凭借对1700多例原发性甲状旁腺功能亢进手术患者的诊治经验，我们报告6例甲状旁腺囊性变导致5例患者出现原发性甲状旁腺功能亢进的病例。
一名67岁女性，4年前手术后因持续性原发性甲状旁腺功能亢进出现高钙血症危象。由于颈部探查未成功，遂行胸骨切开术，从纵隔前部切除了甲状旁腺的囊性腺瘤。第二例患者是一名63岁女性，因严重高钙血症危象接受手术，术前怀疑为甲状旁腺癌，其甲状旁腺功能性囊肿抽吸液中的甲状旁腺激素水平为700,000 pg/ml。第三例，一名70岁患有良性甲状腺肿且有原发性甲状旁腺功能亢进实验室检查结果的女性，手术发现甲状腺旁有一个囊性腺瘤，其抽吸液中的甲状旁腺激素水平为1,500,000 pg/ml。第四例，一名67岁女性，超声检查发现右下甲状旁腺腺瘤，通过电视辅助手术切除了囊性甲状旁腺腺瘤。第五例患者是一名66岁女性，上纵隔发现一个囊性结构，最初怀疑是甲状腺左下极的甲状腺囊肿。甲状腺次全切除术后病理评估显示为一个大的甲状旁腺囊肿。最后一例是一名56岁男性，说明了对一名术前诊断为甲状腺囊肿的原发性甲状旁腺功能亢进患者进行的广泛术前检查。最终组织病理学检查发现为多腺体疾病，伴有甲状旁腺腺瘤以及一个甲状旁腺囊肿。
甲状旁腺囊性腺瘤常被误诊为甲状腺囊肿，或者在甲状旁腺激素水平极度升高的情况下，甚至被误诊为甲状旁腺癌。常规的术前诊断工具，如超声检查或（99m）锝- sestamibi闪烁扫描，无法明确区分这些病变，并且可能因纵隔定位而受到影响，这在伴有囊性变的甲状旁腺腺瘤中并不少见。
