Interdisciplinary Cohesion in Managing a Case of Parathyroid Adenoma: A Case Report

Marquess Raj Swamynathan, Department of Surgical Pathology, Apollo Health and Lifestyle Limited, Chennai, India, Email: marquessraj05@gmail.com

Received: 24-Jul-2023, Manuscript No. EJMJIH-23-106485; Editor assigned: 27-Jul-2023, Pre QC No. EJMJIH-23-106485 (PQ); Reviewed: 11-Aug-2023, QC No. EJMJIH-23-106485; Revised: 18-Aug-2023, Manuscript No. EJMJIH-23-106485 (R); Published: 28-Aug-2023

List of Abbreviations

PTH: Parathyroid hormone; C: Centigrade; Km: Kilometres; LIS: Laboratory Information System

Introduction

Interdisciplinary cohesion is indispensable in patient management. Exchange of scientific information between the various specialties of medicine paves the way forward to productive patient outcomes. We share an example of interdisciplinary cohesion in the management of a patient with parathyroid adenoma.

Parathyroid adenoma is a benign neoplasm derived from parathyroid parenchymal cells. The parathyroid glands play a key role in calcium homeostasis. Parathyroid adenomas are responsible for hyperparathyroidism in 30% to 90% of the cases [1]. Hyperparathyroidism can present with a multitude of symptoms. Some as innocuous as generalized weakness and some which may involve pain such as renal stones. Even psychiatric manifestations have been described in hyperparathyroidism.

Hence a patient with hyperparathyroidism could seek the help of the various specialists in medicine ranging from endocrinologists to urologists. Cohesion, exchange of ideas and a patient centric approach is essential in management of such cases. The old adage ‘too many cooks spoil the broth’ is a reminder that conflict and exertion of superiority of one branch to another will not augur good for the patient. Our case report is an illustration of how teamwork and an interdisciplinary approach between different branches of medicine will stand the patient in good stead [2].

Case Presentation

A 74-year-old man presented to the surgeon with nephrolithiasis, weakness and fatigue. An endocrinologist’s opinion was sought. It came to light through radionuclide scan and parathormone (PTH) testing that the patient harboured a parathyroid adenoma. A diagnosis of primary hyperparathyroidism was established.

The surgeon had planned for left lower parathyroidectomy in his hospital and testing for intraoperative PTH levels. A drop in the IOPTH>50% is considered as successful excision of the parathyroid glands [3-5]. However, the hospital laboratory did not have the facility to test of intraoperative PTH levels. The clinical team came in touch with the laboratory team of Apollo diagnostics. The reference laboratory of Apollo diagnostics was situated 20 km away from the location where the surgery was to take place.

However, with meticulous planning and exchange of ideas, it was decided that the surgery be performed in the early hours of a Sunday morning. The early hours of Sunday were chosen to avoid the brunt of the city’s traffic. The base line as well as IOPTH samples were transported to the testing facility by ambulance within an hours’ time and the samples were tested after all the pre-requisites for sample testing such as QC checks were passed. The results were satisfactory as the drop in PTH level was >50 %

The excised glands were subjected to histopathological study and the diagnosis of parathyroid adenoma was confirmed.

Results and Discussion

Parathyroid adenomas are the commonest cause of primary hyperparathyroidism and account for 85% to 95% of the cases [1,6]. Patients with parathyroid adenoma can present with bone disease, nephrolithiasis, gastrointestinal disturbances, central nervous system alterations and cardiac manifestations (Figure 1).

Figure 1. Pre-operative PTH levels as shown in the laboratory LIS.

Grossly, parathyroid adenomas tend to be located in the lower glands>upper glands and the same held true in our patient. However, despite many attempts the best imaging technique for localizing abnormal parathyroid tissue, the best “technique” for successful localization of abnormal parathyroid glands is an experienced surgeon (Figure 2).

Figure 2. Intra-operative PTH levels as shown in the laboratory LIS.

The patient on whom left lower parathyroidectomy was done presented with nephrolithiasis, weakness and fatigue. The radionuclide scan as well as PTH levels of the patient suggested primary hyperparathyroidism and the cause were ascribed to parathyroid adenoma. It is worth recalling that parathyroid adenomas are associated with MEN (multiple endocrine neoplasias) syndromes [7].

Intraoperative estimation of PTH is termed biochemical frozen section. The expertise of the biochemist cannot be understated and thorough scrutiny of pre-requisites such as Quality Control (QC), analyser maintenance and sample acceptability criteria were given due attention prior to the testing of the samples [8].

On the basis of the Irvin criterion, an intraoperative PTH drop >50% from the highest either pre incision or pre excision level after parathyroid excision was considered a surgical success. Both baseline and intraoperative PTH samples were collected from the patient and were transported to the testing facility within 1 hour. The percentage difference between pre-operative and intraoperative PTH levels was 165 %, which satisfied Irvin criterion [1,5,6].

Histopathological examination

The left lower parathyroid gland received in the laboratory was weighed before cutting. The weight of the parathyroid gland was 3 grams. As given in literature the weight of the parathyroid rarely exceeds 1 gram if the underlying pathology is hyperplasia [9].

As stromal fat is completely absent in parathyroid adenomas. Demonstration of the same by means of tissue frozen section is described in literature as a means of differentiating adenoma from hyperplasia. However, the risk incurred by not performing a frozen section was evaluated in this case. The surgeon and the laboratory team concluded that documentation of IOPTH levels and routine histopathological examination would suffice in confirming a diagnosis of parathyroid adenoma [6-8].

The parathyroid glands received in the laboratory after surgery had a discrete nodular appearance suggesting adenoma. On cutting, the surface of the parathyroid was homogenous gray white with areas of congestion. The gland was subjected to histopathological examination (Figure 3).

Figure 3. Gross image of the left lower parathyroid shows homogenous gray white surface and specks of congestion.

Parathyroid adenomas, grossly are well circumscribed tumours or encapsulated tumours oval tumours measuring 1 cm to 3 cm. Chief cells are the predominant cells in parathyroid adenomas, however other cell types can be present in varying mixtures (Figure 4). The presence of clusters of cells with bizarre nuclei is fairly common and does not indicate malignancy. Stromal fat is more often than not absent in parathyroid adenomas and is considered a diagnostic feature (Figure 5). Likewise, lymphocytic infiltration of the intervening stroma and occasional mitoses are common features in otherwise benign parathyroid adenomas [9].

Figure 4. Photomicrograph (4x). Microscopic examination done on sections taken from the parathyroid revealed sheets of eosinophilic cells in an acinar pattern with interspersed delicate vessels on low power.

Figure 5. Photomicrograph (40x). Sections studied from the parathyroid showed sheets of polygonal cells with abundant cytoplasm, vesicular nuclei and ‘salt and pepper’ chromatin.

A diffuse growth pattern is the most frequent type of architecture encountered, but follicular, nesting, or pseudo papillary patterns may be encountered (Figure 6). Though immunohistochemistry has been described as an ancillary tool to study parathyroid neoplasms further, it is seldom required. In our patient, the gross and microscopic findings did show characteristic features of parathyroid adenoma and the same correlated with the clinical as well as biochemical findings [10].

Figure 6. Photomicrograph (40x). On higher power few areas showed cells with bizarre nuclei and binucleate cells. However, no necrosis or mitoses were noted.

Conclusion

The biochemical findings and histopathology findings confirmed a diagnosis of parathyroid adenoma in patient who presented with symptoms of primary hyperparathyroidism.

Interdisciplinary participation in patient management is vital towards positive patient outcomes. Rapport and discussion between the various disciplines in medicine as well as the culture of ‘putting the patient first’ resulted in a positive outcome and successful management of the patient.

Declarations

The authors have no conflict of interest to declare.

Availability of Supporting Data and Materials

The PTH and histopathology reports bearing the names of the authors, who also functioned in the capacity of authorised signatories, have been emailed to the editor. The letter head of Dr. D.S Kumaresan, the surgeon with request for histopathological examination of the surgical specimen has also been emailed.

Competing Interests

There are no competing interests.

Funding

No funding was received and the study was done out of academic interest.

Author's Contributions

Dr. Marquess Raj is the primary author who led the study. Dr. D.S. Kumaresan. Was the surgeon who performed the surgery Dr. Chidambharam C studied the histopathology slides along with the primary author. Dr. Srivatsan. R was the biochemist, who ensured that QC checks were run prior to the testing of PTH levels and validated the results.

Dr. Sivaramakrishnan, a molecular biologist and also laboratory manager helped, organise the activity of PTH testing on the day of surgery and coordinated dialogue between the clinical and stakeholders’ in the lab medicine team.

Acknowledgement

The authors profusely thank the management of Apollo health and lifestyle limited and the leadership team of Apollo Diagnostics for allowing us to publish this study.

Author Information

The corresponding author is a pathologist with over 12 years’ experience in histopathology and lab medicine practice.

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