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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 3  |  Page : 313-320
Primary hyperparathyroidism: A clinicopathological experience

1 Department of Pathology, Seth G. S. Medical College, Mumbai, India
2 Department of Endocrinology, Seth G. S. Medical College, Mumbai, India

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Date of Web Publication12-Aug-2009


Background: Parathyroid neoplasms form a small percentage of head and neck neoplasms. Primary hyperparathyroidism is caused by parathyroid adenomas, hyperplasia or, rarely, a carcinoma. Materials and Methods: This is a retrospective study of 48 parathyroidectomies received in the Department of Pathology of a major teaching hospital over a period of 10 years. Clinical, biochemical and radiological details were retrieved from medical records. Information regarding routine gross and microscopic examination findings (including frozen section and paraffin sections) was retrieved from departmental records. Results: We had 43 adenomas, three hyperplasias and two carcinomas. The most common age group was 21-30 years. The female:male ratio was 2.5:1. Most patients presented with skeletal manifestations. The pre-operative diagnosis was assisted by ultrasonography in 11 cases, computerized tomography of the neck in 10 cases and sestamibi scans in three cases. Intra-operative parathormone monitoring was performed in one case of adenoma. Frozen section was requested in 28 of 48 cases. There was a discrepancy between frozen section diagnosis and paraffin section diagnosis in two cases. Conclusion: Histopathologic diagnosis is an important guide to decide the type of surgical management. Although pathologic features of parathyroid carcinoma are diagnostically reliable, those of the more commonly encountered lesions of adenoma and hyperplasia may be overlapping and, therefore, indistinctive, more so if only a single gland is available for examination. Because parathyroid lesions are only occasionally encountered by the surgical pathologist, awareness of the spectrum of histologic features along with knowledge of recent trends in diagnosis and surgical management are important.

Keywords: Clinicopathologic corelation, parathyroid, tumor, primary hyperparathyroidism

How to cite this article:
Sathe PA, Madiwale CV, Kandalkar BM, Bandgar TR, Shah NS, Menon PS. Primary hyperparathyroidism: A clinicopathological experience. Indian J Pathol Microbiol 2009;52:313-20

How to cite this URL:
Sathe PA, Madiwale CV, Kandalkar BM, Bandgar TR, Shah NS, Menon PS. Primary hyperparathyroidism: A clinicopathological experience. Indian J Pathol Microbiol [serial online] 2009 [cited 2021 May 6];52:313-20. Available from: https://www.ijpmonline.org/text.asp?2009/52/3/313/54983

   Introduction Top

Primary hyperparathyroidism can result from autonomously functioning adenoma (85% cases), hyperplasia (14% cases) or, rarely, carcinoma (1% cases) . [1],[2] Adenoma and hyperplasia share many histologic features, which results in difficulties in differentiation. This distinction is important as adenoma requires excision of a single diseased gland while hyperplasia requires removal of three and a half glands with autotransplantation of the remaining tissue. Parathyroid carcinoma needs concomitant hemithyroidectomy in addition to removal of the affected gland. Correct diagnosis is achieved only after corelating the pathologic findings with the clinical setting, results of biochemical and radiological investigations and the status of other glands, which is often assessed intra-operatively. Erroneous interpretation by the surgical pathologist can result in over or undertreatment, with complications such as hypocalcemia or persistence of symptoms.

Even in a large medical center, parathyroid tissue constitutes only a small percentage of surgical pathology workload. There are very few Indian publications dealing with parathyroid pathology. [3],[4],[5] Hence, we felt that a retrospective pathologic analysis of parathyroid lesions and their clinicopathologic corelation would be a useful exercise.

   Materials and Methods Top

This is a retrospective analysis of 48 cases of primary hyperparathyroidism operated at a tertiary care, teaching hospital over a period of 10 years from June 1997 to May 2007. Clinical data and details of biochemical, radiological and other investigations were obtained from the indoor charts. Information regarding gross and microscopic features (including frozen section) was retrieved from departmental records.

The pathologic parameters assessed were:

Gross features

Number of glands removed, size, weight, presence of capsule, cut surface and presence of identifiable peripheral parathyroid tissue.

Microscopic features

Presence of capsule, cell composition, architectural patterns, nuclear features, presence of coagulative necrosis, mitosis, fibrous bands, vascular and capsular invasion and infiltration into surrounding structures.

Cases were categorized as follows:


Encapsulated hypercellular lesion, predominantly single-cell population, absence of stromal adipocytes, lesion confined to single gland confirmed histologically.


Hypercellular lesion, heterogeneous population of proliferating cells, reduction of stromal adipocytes, involvement of more than one gland.


Capsular and vascular invasion, infiltration into surrounding structures.

   Results Top

The 48 parathyroid lesions constituted 0.07% of the surgical pathology workload of a total of 69,987 tissues received during the study period. There were 43 cases of parathyroid adenoma, three cases of parathyroid hyperplasia and two cases of parathyroid carcinoma.

Demographic and clinical data

The age range was from 16 to 58 years. Fifteen cases (31.2%) were between the age of 21 and 30 years. There were 34 female patients, with a female:male ratio of 2.5:1.

Clinical manifestations are shown in [Table 1]. Skeletal symptoms were the predominant presenting feature. Associated diseases included cardiomyopathy and acanthosis nigricans (two cases each) and infertility (one case). Two cases had a palpable neck mass. Combined skeletal and renal manifestations were seen in 11 adenomas and one case of carcinoma. There were no familial or asymptomatic cases in our study.

Biochemical findings

Levels of total serum calcium, which were periodically performed, were available in all cases. The highest pre-operative level is considered in all cases. The range for adenomas was between 10.7 and 16.6 mg/dl and for hyperplasia was between 10.8 and 13.1 mg/dl. The levels in two cases of carcinoma were 14.6 and 11 mg/dl. One case of parathyroid adenoma was normocalcemic.

Pre-operative serum parathormone (PTH) levels were available in 41 cases. The range for adenomas was between 134 and 2500 pg/ml and for hyperplasia was 225-322 pg/ml. PTH level was available in only one case of carcinoma, which was 1014 pg/ml.

Serum alkaline phosphatase levels were available in 33 cases, and the values ranged from 33 to 4873 U/L in all cases. Serum phosphorus was available in 37 cases and the range was 0.9-4.2 mg/dl. The other biochemical parameters available were serum creatinine in five cases, with a range from 1.6 to 3.8 mg/dl, and urinary calcium, with a range from 15.4 to 805 mg/dl in 24 h.

Radiological and sestamibi scan findings

Ultrasonography (USG) interpretation matched with the pathologic diagnosis in nine out of 10 cases of adenoma in which it was performed whereas in one case, the USG impression was not specified and was recorded only as parathyroid lesion. USG was performed in a single case of hyperplasia and reported as adenoma.

Computerized tomography (CT) of the neck was performed in nine adenomas and one carcinoma. CT interpretation matched with the pathologic diagnosis of adenoma in all cases except in one case where a differential diagnosis of hyperplasia was given. Parathyroid carcinoma had been interpreted as adenoma based on CT scan.

X-rays of long bones, vertebrae and skull had been performed in 17 cases. All cases showed typical features of hyperparathyroidism (pepper pot skull, cod fishing of vertebrae, osteopenia, osteolytic lesions and fractures of long bones). One case of adenoma showed features typical of osteitis fibrosa cystica.

Sestamibi scan was performed in only three cases, which suggested a diagnosis of adenoma that was confirmed histologically.

Intra-operative findings

In all our cases, parathyroid tissue was located in the neck. Intra-operatively, both cases of parathyroid carcinoma were hard in consistency and difficult to mobilize owing to adhesions. Only one case of adenoma appeared adherent and difficult to remove. Intra-operative monitoring of PTH levels was performed in only one case of adenoma. There was over a 50% drop in the pre-operative levels of PTH 10 min after excision of the enlarged gland.

Pathologic findings

Gross features seen in our cases were as follows: (summarized in [Table 2]).

The maximum weight in our series was a 26-g parathyroid adenoma. Average weight of adenomas was 4.2 g. The two parathyroid carcinomas were 6 and 11 g in weight. The average weight for hyperplasia (single gland) was 1.03 g. Adenomas and hyperplasia generally had a nodular smooth surface and variable color. Very firm consistency, white fibrous streaks, minute foci of necrosis on cut surface and adherent thyroid gland and skeletal muscle were characteristic features of carcinoma. In both cases of carcinoma, difficulty in mobilization and separation from thyroid resulted in concomitant total thyroidectomy. Hemithyroidectomy was also performed in four cases of adenoma (for nodular goiter in three cases while the fourth case had adhesions following prior surgery).

Histologic features seen in our cases were as follows: [Table 3].

Diagnosis of adenoma was made in 38 cases when single-gland involvement was established by concomitant sampling of an additional gland that proved to be normal by frozen section. In the remaining five cases, diagnosis of adenoma was given based on single-gland examination due to confirmatory sestamibi scan and CT findings. Among the three cases of hyperplasia, three and a half glands had been removed in each case after confirmation as hyperplasia on frozen section examination.

Parathyroid adenoma: [Figure 1]a-d

All cases of adenoma showed encapsulation and absence of stromal fat. Extracapsular parathyroid tissue and chief cell predominance were noted in 37 adenomas. Mixture of chief cells and oxyphil cells was seen in six cases. Other noteworthy but common features of adenoma are described with number of cases in parentheses: nucleomegaly (43), cystic change (3), hemorrhage (7), follicle formations and intraluminal eosinophilic material reminiscent of thyroid tissue (7). Rarely described features were [Figure 1]b small, non-invasive islands of cells trapped within the capsule (3), infrequent mitoses (5) and foci of bizarre cells (3).

Parathyroid hyperplasia

Features of hyperplasia were lack of capsule and mixed cell population, with predominance of chief cells. Stromal adipocytes were reduced but were present in all three cases.

Parathyroid carcinoma : [Figure 2]a-e

Both cases showed broad intersecting fibrous bands, capsular and vascular invasion, foci of coagulative necrosis and extension into adjacent connective tissue, skeletal muscle and thyroid. Mitoses and nuclear atypia were infrequent.

Frozen section results: [Table 4]

Difference between frozen and paraffin diagnosis was noted in only two of 43 cases of parathyroid adenoma. Frozen diagnoses offered here were follicular lesion of the thyroid in one case and normal parathyroid in the second case. In one case of adenoma, the diagnosis deferred as fibrosis was conspicuous. There was agreement between frozen and paraffin diagnosis in all three cases of hyperplasia. The diagnosis of parathyroid carcinoma was suspected at frozen section in the single case where it was performed.

Follow-up information

In the immediate post-operative period, 15 patients (14 adenomas and one carcinoma) developed paresthesia, tingling numbness and hungry bone syndrome due to hypocalcemia and required oral calcium supplements. Long-term follow-up was not available.

   Discussion Top

The incidence of primary hyperparathyroidism is 2.5 per 1000 individuals. [3],[5],[6] It has a female preponderance, as is also seen in our study. Our cases had classic manifestations of hyperparathyroidism, including skeletal, renal, neuromuscular and neuropsychiatric manifestations, and secondary features like polyuria and polydipsia [Table 1]. Western literature reports a changing clinical pattern of primary hyperparathyroidism, wherein patients are often asymptomatic and the hypercalcemia may be incidentally detected. [6],[7] We had no such asymptomatic cases in our study. As noted in other Indian studies, we also found a striking predominance of skeletal manifestations. A proposed explanation for this is that our population has pre-existing vitamin D deficiency. [3],[4],[5],[7] Changes of osteitis fibrosa cystica are rare. [8] These were seen in 10 cases in our study. Pancreatitis is a well-known association with primary hyperparathyroidism and was noted in three of our cases. One patient had acanthosis nigricans, but we found no correlation with hyperparathyroidism. One case each of parathyroid adenoma and carcinoma presented with palpable neck nodule. Although palpable mass is more often a feature of carcinoma, parathyroid adenoma may occasionally present in this manner. [2]

Characteristic biochemical profile of hypercalcemia and high PTH levels was noted in our cases. However, there was one case with repeated normocalcemia. This patient had bone fracture and brown tumor and the PTH levels were 220 pg/ml. There were no features of pancreatitis in this case, which is known to lower the serum calcium levels in these patients. There are only few reports of normocalcemic hyperparathyroidism. [9],[10] Yang et al . have shown that the parathyroid tissue in these cases lacks significant alterations in calcium-sensing receptors. [11] Another possible explanation is that serum calcium may be only intermittently elevated and that levels of ionized calcium being more sensitive, this should be tested rather than total calcium. [12]

Severe hypercalcemia is generally a feature of parathyroid carcinoma. [13] However, the highest serum calcium levels of 16.6 mg/ dl were noted in a parathyroid adenoma weighing 26 g. The size of the parathyroid lesion is related with the severity of hypercalcemia. [2]

Pre-operative imaging was performed in only few cases and the impression in most matched with the histologic diagnosis. Literature search yields reasons for and against the pre-operative use of these investigations and they are more useful in the surgical management of patients with post-operative recurrent or persistent hyperparathyroidism. [14],[15],[16] Sestamibi scan was performed in three of our cases. It is a more precise tool, with a sensitivity of 100% and a specificity of 90% for adenomas. [14]

We noted that 89.5% of our cases with primary hyperparathyroidism were due to adenomas. This coincides with literature reports. [1],[3],[5],[13] Nodularity, tan brown color and firmness were the most common gross features of adenoma. However, variation in color, consistency and appearance was also observed [Table 2]. Hence, intra-operatively, parathyroid tissue may resemble tissues such as fat, lymphnode, thyroid and thymus and frozen section may be required to confirm the nature of the tissue. [17]

In our study, the diagnosis of adenoma was made only after histologic sampling of at least one more gland. Diagnosis based on single-gland sampling was carried out in only five cases in which pre-operative imaging was confirmatory. Traditional surgical approach relies on bilateral neck dissection with exploration of all four parathyroid glands. [8] However, there exists a risk of post-operative hypocalcemia and success rates of unilateral neck exploration are comparable. Anton and Wheeler are of the opinion that the need to biopsy additional glands is best based on intra-operative judgement regarding weight. In this context, it is useful to remember that abnormal parathyroid tissue weighs over 60 mg and measures over 7 mm. [8],[17] There have been occasional reports of double adenomas. [18] However, all our cases were solitary.

Encapsulation and presence of extracapsular compressed parathyroid tissue are distinctive features of adenoma. [17] Peripheral parathyroid tissue was not seen in 12 of our adenomas, which may be due to complete replacement of the gland by the lesion. Some architectural features observed in our cases can be potentially misleading. Follicular architecture with intra-luminal colloid-like material was seen in seven cases and in one case, it was interpreted as follicular lesion of the thyroid at frozen section. Trapped cells within the capsule should not be mistaken for capsular invasion. [2] Areas of fibrosis may be present in adenomas and these may be confused with the broad fibrous bands of carcinoma. [19] We saw extensive fibrosis present in a case of recurrent parathyroid adenoma [Figure 1]d. In recurrent adenomas, possibility of overlooked hyperplasia, carcinoma or double adenoma must be excluded. Our case was difficult to mobilize due to post-operative fibrous adhesions but there was no soft tissue invasion, which characterizes a carcinoma. Hyperplasia was ruled out by examining one more gland. Previous slides and detailed notes of this case were also unavailable for review. Parathyroid adenomas may rarely recur due to accidental seeding at surgery. [1] This possibly is the likely explanation in this case. Stromal adipocytes were absent in all our adenomas but may predominate in lipoadenomas. These can be distinguished from normal parathyroid tissue by their larger size. [20]

A majority of our adenomas were composed predominantly of chief cells. This was also observed in other studies. [3],[5] Pure oxyphil cell adenomas are known to be non-functional and have lesser degrees of hypercalcemia. [2] Nucleomegaly was seen in all our cases. Mitoses, bizarre nuclei and nuclear atypia were seen in few cases. These features are common in benign endocrine neoplasms and, by themselves, are not indicative of malignancy. [17]

Parathyroid hyperplasia constituted 6% of our cases. One case showed three-gland involvement, while two-gland involvement was noted in the remaining two cases. All our cases showed enlarged glands, but it is known that hyperplasia may involve the glands in an unequal fashion and result only in minimal gland enlargement. There may be histologic overlap between hyperplasia and adenoma and hence it is emphasized that sampling of more than one gland is essential. [2],[17] The di s tinction between adenoma and hyperplasia is important as the treatment differs. [8]

Post-operative persistence of hypercalcemia and recurrence of symptoms among cases diagnosed as adenomas may imply that these actually represent hyperplasia. In our study, drop in serum calcium levels in the immediate post-operative period was recorded in all except one case of recurrent adenoma and none followed-up with recurrence of symptoms. It is therefore unlikely that any of our adenomas actually represented hyperplasia.

Parathyroid carcinomas are rare. [13],[1] These were seen in 4.2% of our cases. The diagnosis was suspected intra-operatively as there was difficulty in mobilization due to infiltration into adjacent tissues. Invasive nature and histologically documented evidence of regional or distant metastases are two unequivocal features of malignancy. Presence of any one of these suffices for diagnosis of carcinoma. [2] Both our cases showed invasion into skeletal muscle and thyroid. Other structures that may be invaded are esophagus and nerves. Parathyroid carcinomas are usually over 1 g in weight. [2],[13] Our two cases weighed 6 and 11 g. Other features associated with malignancy, such as capsular and vascular invasion, intratumoral broad fibrous bands, coagulative tumor necrosis and sheet-like proliferation of monotonous small cells were also present in our cases of carcinoma. It must be remembered that in the absence of absolute criteria of malignancy, two or more of these need to be present to make a diagnosis of carcinoma. [2] Groups of parathyroid cells within vascular lumina and present trapped in the capsule are described in adenoma and should not be interpreted as malignancy. [17] Hence, criteria for capsular and vascular invasion should be the same as those used in the diagnosis of follicular carcinoma of the thyroid. [2] Both our cases demonstrated minimal nuclear atypia and scarcity of mitoses. It is also well known that parathyroid carcinoma may show a variable histologic appearance, ranging from deceptively bland-looking tumors mimicking adenomas to frankly malignant tumors. Hence, diagnosis of malignancy is often based on a constellation of pathologic as well as clinical and biochemical features, including palpable neck mass and very high serum calcium levels. [2],[13] Cases lacking absolute criteria of malignancy but demonstrating some worrisome features are described as atypical parathyroid adenoma. [21]

Frozen sections are important in the surgical management of patients with primary hyperparathyroidism as they help in (a) tissue confirmation, (b) deciding whether the sampled parathyroid tissue is normal or abnormal and (c) identifying the nature of the abnormality. [17] The reported diagnostic accuracy of parathyroid frozen sections is 99.2%. [17] In our study, difference between frozen and paraffin diagnosis was noted in only two cases. Reasons for discrepancy were (a) presence of numerous thyroid-like follicles in the parathyroid adenoma and (b) judgement error probably secondary to freezing artifact giving an appearance of fat-like spaces, resulting in misinterpretation of parathyroid adenoma as normal parathyroid tissue. These and other factors are described as potential diagnostic pitfalls on frozen section. [17] Frozen diagnosis was deferred in the case of recurrent adenoma as adherence of gland to adjacent structures and intralesional fibrosis created diagnostic confusion with carcinoma. Frozen report was "suspect carcinoma" in one case of carcinoma because broad fibrous bands and difficulty in mobilizing the gland supported the diagnosis. However, only subsequent paraffin sections revealed skeletal muscle invasion .

Some techniques aid in the intra-operative diagnosis of parathyroid lesions. Paucity of intra-cytoplasmic fat is a feature of abnormal parathyroid tissue. This can be demonstrated on touch imprint smears of parathyroid tissue at frozen section. [17] Although simple, the results may be ambiguous. [17] Intra-operative determination of parathyroid hormone is a useful technique.

There are several reports emphasizing the value of intra-operative assay of PTH. [22],[1],[23] This investigation was performed in one of our cases and the decline in PTH levels after removal of the adenoma indicated successful surgical procedure. Based on the pattern of drop in the PTH levels, it may be possible to distinguish between adenoma and hyperplasia. [22],[1] This technique, along with pre-operative localization by sestamibi scans, has played an important role in the success of minimally invasive parathyroid surgery. [ 23],[1],[24] These techniques pinpoint the diseased glands based on function rather than histopathology. Some authors envisage that in future the intra-operative role of the pathologist could be limited to the mere identification of parathyroid tissue. [2],[22],[17],[24] However, there are counter arguments against this. [ 17] Because of the cost and limited availability of these methods, routine histopathological examination still remains the baseline standard diagnostic procedure in our country. Hence, we thought it important to document our surgical pathology findings and share our experience.[Table 3]

   References Top

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2.Chan JK. Tumors of the thyroid and parathyroid glands. In: Fletcher CD, editor. Diagnostic pathology of tumors. 3 rd ed. Elsevier, Churchill Livingstone; 2007. p. 997-1097.  Back to cited text no. 2    
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10.Wills AR, Pak CY, Hammond WG, Bartter FC. Normocalcemic primary hyperparathyroidism. Am J Med 1969;47:384-91.  Back to cited text no. 10    
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24.Carneiro-Pla DM, Romaguera R, Nadji M, Lew JI, Solorzano CC, Irvin GL 3 rd . Does histopathology predict parathyroid hypersecretion and influence correctly the extent of parathyroidectomy in patients with sporadic primary hyperparathyroidism? Surgery 2007;142:930-5.  Back to cited text no. 24    

Correspondence Address:
Pragati A Sathe
A/7, Jeevan Sudha Society, C.D. Barfiwala Road, Andheri West, Mumbai - 400 058
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.54983

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