Parathyroid FNA with PTH determination as a tool in primary hyperparathyroidism diagnosis case report
Jeanina Idriceanu1, Lidia Ionescu2, Claudia Miron1, Roxana Balcan1, Safae ElMekkaoui1, Ioana Vasiliu1, Voichita Mogos1 & Carmen Vulpoi1
I fine-needle aspiration (FNA) is the gold standard in thyroid nodules management, but it is less common in the evaluation of parathyroid nodules. When imagery fails to localize a parathyroid adenoma, morphological and functional investigations, like FNA of the suspected area and scintigraphy may be useful. We present the case of a 58 years-old woman, menopaused at 47 years, who consulted for lombalgia. Vertebral DXA confirmed osteoporosis (Tscore −3.8). She was not treated with HRT or calcium and vitamin D. Biological assessments revealed hypercalcemia (10.92 mg/dl), low normal phosphorus (2.94 mg/dl) and hypercalciuria (400 mg/24 h) suggesting primary hyperparathyroidism, confirmed by elevated PTH (111.8 pg/ml, N:15−65 pg/ml). Specifically associates forearm osteoporosis (Tscore −3.2). Thyroid function was normal (TSH=1.8 μUI/ml, fT4=1.3 ng/dl) and thyroid ultrasound described a right inferior nodule of 1.4 cm, izoechoic, with well defined margins and mild internal vascularization. CT identified thyroid hypoechoic nodules bilateral of maximum 7 mm in diameter, without signs of a parathyroid adenoma. Ultrasound-guided FNA of the nodule with dosage of PTH level in the needle-wash was performed. Cytology was not conclusive, but the high levels of intranodular PTH (1021 pg/ml) confirmed that the nodule was a parathyroid adenoma.
Parathyroidectomy was successfully performed (pathology: clear cells adenoma), followed by normalization of PTH and calcium parameters. Minimally invasive parathyroid surgery is the treatment of choice in primary hyperparathyroidism but a successful removal requires the clear localization of a parathyroid lesion. US-guided FNA is a useful technique, literature data confirming a high specificity and sensitivity (>90%). In our case, very high level of PTH in the needle-wash identified parathyroid adenoma, avoiding extensive surgery for a mild hyperparathyroidism. The post surgery normalization confirmed the the good localization, proving the efficacy of the method in primary hyperparathyroidism diagnosis.