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Vol. 96. Issue 1.
Pages 52-54 (January 2018)
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Vol. 96. Issue 1.
Pages 52-54 (January 2018)
Scientific letter
DOI: 10.1016/j.cireng.2018.01.004
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Non-Functioning Parathyroid Cysts Refractory to Conservative Treatment
Quistes no funcionantes de paratiroides refractarios al tratamiento conservador
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José Ruiza,b, Antonio Ríosa,c,
Corresponding author
arzrios@um.es

Corresponding author.
, José Manuel Rodrígueza,c, Pascual Parrillaa,c
a Departamento de Cirugía, Ginecología Obstetricia y Pediatría, Universidad de Murcia, Murcia, Spain
b Servicio de Cirugía General y de Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Servicio Murciano de Salud, Murcia, Spain
c Instituto Murciano de Investigación Bio-Sanitaria Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain
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Tables (1)
Table 1. Characteristics of Patients With Recurrent Non-Functioning Parathyroid Cysts.
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Parathyroid cysts were first described in 1880 by Sandström, but the first surgical resection was not performed until 1905 by Goris. These cysts can be classified as functioning, which occur with primary hyperparathyroidism, or non-functioning. The latter are the most frequent, representing 80%–90% of all parathyroid cysts.1,2 In addition, cystic parathyroid lesions account for 0.075% of cervical ultrasounds.3

Functional parathyroid cysts are managed like primary hyperparathyroidism, whose treatment of choice is surgery. Thus, functioning parathyroid cysts account for 3% of parathyroidectomies performed by primary hyperparathyroidism.4

In contrast, the management of non-functioning cysts is conservative, with drainage by needle aspiration being the treatment of choice. Regarding the etiopathogenesis of these non-functioning cysts, there are 2 theories: the first is that they originate in the embryonic period from the 3rd and 4th pharyngeal arches; the second indicates that they originate by fusion of parathyroid microcysts caused by degeneration of the gland or retention of secretions that form microcysts.1

The objective of this case report is to analyze the management of non-functioning parathyroid cysts refractory to drainage with needle aspiration.

Patients with parathyroid cysts that met the following criteria are included in this report: (a) ultrasound or computed tomography (CT) diagnosis of parathyroid cysts; (b) fluid obtained by needle aspiration, with limited cellularity and a concentration of parathyroid hormone (PTH) greater than in plasma (>9–65pg/ml); (c) no hyperparathyroidism (normal plasma PTH and calcium levels); (d) previous treatment with percutaneous drainage; and (e) recurrence of the cyst, with a size greater than 3cm in diameter.

Four patients met the inclusion criteria (Table 1), which represents 0.43% of all parathyroid disease treated surgically at our hospital in the same period of time. Excluded from the series were 3 treated parathyroid cysts as they were functioning and treated as primary hyperparathyroidism. 75% (n=3) of patients were male and mean age was 37.7±13.8 years. 75% (n=3) of the non-functioning cysts were located in the left lower parathyroid gland. In the 4 cases (100%), surgery was indicated, entailing parathyroidectomy of the affected gland. Being non-functioning cysts, they did not require intraoperative monitoring of PTH. There were no complications in the postoperative period. After a mean follow-up of 13.2±8.9 years, the patients have not presented recurrence of the disease.

Table 1.

Characteristics of Patients With Recurrent Non-Functioning Parathyroid Cysts.

  Case 1  Case 2  Case 3  Case 4 
Age (yrs)  43  55  27  26 
Sex  Female  Male  Male  Male 
Symptoms  Asymptomatic  Cervical discomfort when swallowing  Asymptomatic  Cervical discomfort when swallowing 
Physical examination  Palpable and non-painful left cervical nodule  Palpable and painful left cervical nodule  Palpable and non-painful left cervical nodule  Palpable and painful right cervical nodule 
Analysis
Ca (mg/dL)  9.5  9.6 
P (mg/dL)  3.5  2.3  4.1  3.3 
PTH (mg/dL)  24  39  22  11 
TSH (IU/mL)  3.66  2.34  1.55  1.88 
T4l (ng/dL)  1.24  1.18  1.34  1.60 
Ultrasound  4.2cm cyst in the lower pole of the LTL  4.8cm cyst in the lower pole of the LTL  4cm cyst in the lower pole of the LTL  3.4cm cyst in the lower pole of the RTL 
FNA
Cytology  Clear liquid with limited cellularity  Clear liquid with limited cellularity  Clear liquid with limited cellularity  Clear liquid with limited cellularity 
PTH (pg/mL)  2001  370  443  400 
No. of previous aspirations 
Surgery  Yes  Yes  Yes  Yes 
Resected gland  LIPG  LIPG  LIPG  RIPG 
Complications  No  No  No  No 
Histopathology  Parathyroid cyst  Parathyroid cyst  Parathyroid cyst  Parathyroid cyst 
Follow-up (yrs)  21  20  10 
Recurrence  No  No  No  No 

RIPG: right inferior parathyroid gland; LIPG: left inferior parathyroid gland; RTL: right thyroid lobe; LTL: left thyroid lobe; FNA: fine-needle aspiration.

Non-functioning parathyroid cysts are usually asymptomatic,2,5 except those that reach a size greater than 3cm, which tend to cause symptoms due to the compression of neighboring structures.1,2 The initial treatment is percutaneous drainage, which is ambulatory and can resolve the condition in up to 50% of cases, or at least maintain it at a size that does not produce compressive symptoms.6

In cases of cyst recurrence after aspiration with an acquired size greater than 3cm, a more definitive treatment is recommended. Some authors propose further needle-aspirations, but in most cases there are new cyst recurrences.7,8 The most effective treatment is surgery, as it achieves definitive resolution of the cyst. Classically the main reason against surgery was the associated morbidity. Today, however, in experienced endocrine surgery units, this surgery is performed with practically no morbidity,9,10 as observed in our series. Remember that, as it is neither tumor tissue nor functioning, the risk of parathyromatosis in case of rupture of the cyst is virtually non-existent.

In recent years, other non-surgical therapeutic alternatives have been developed and promoted. For instance, radiofrequency has been gaining indications in benign disease, both thyroid and parathyroid, with promising results. However, the experience to recommend its use in parathyroid disease is minimal, especially in cystic lesions where the results are worse than in solid lesions. Sclerosis with tetracycline or ethanol7,11 has been recommended by some authors, and has even been recommended as a second therapeutic step after the failure of percutaneous drainage by needle aspiration. However, parathyroid cysts >3cm, because of their size, are usually close to the recurrent nerve, which is frequently injured. Therefore, our group does not recommend this technique. In any case, we should keep in mind that, given the lack of experience in this disease, recommendations cannot be restrictive.

In conclusion, for the treatment of non-functioning parathyroid cysts refractory to percutaneous needle-aspiration drainage, surgery is a safe and effective therapeutic option in endocrine surgery units.

References
[1]
N. Pontikides, S. Karras, A. Kaprara, A. Cheva, A. Doumas, D. Botsios, et al.
Diagnostic and therapeutic review of cystic parathyroid lesions.
Hormones (Athens), 11 (2012), pp. 410-418
[2]
E.D. Rossi, L. Revelli, E. Giustozzi, P. Straccia, E. Stigliano, C.P. Lombardi, et al.
Large non-functioning parathyroid cysts: our institutional experience of a rare entity and a possible pitfall in thyroid cytology.
Cytopathology, 26 (2015), pp. 114-121
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C. Cappelli, M. Rotondi, I. Pirola, E. de Martino, P. Leporati, F. Magri, et al.
Prevalence of parathyroid cysts by neck ultrasound scan in unselected patients.
J Endocrinol Invest, 32 (2009), pp. 357-359
[4]
K.L. McCoy, J.H. Yim, B.S. Zuckerbraun, J.B. Ogilvie, R.L. Peel, S.E. Carty.
Cystic parathyroid lesions functional and nonfunctional parathyroid cysts.
Arch Surg, 144 (2009), pp. 52-56
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G. Ippolito, F.F. Palazzo, F. Sebag, M. Sierra, C. de Micco, J.F. Henry.
A single-institution 25 year review of true parathyroid cysts.
Langenbecks Arch Surg, 391 (2006), pp. 13-18
[6]
R.A. Prinz, J.R. Peters, J.M. Kane, J. Wood.
Needle aspiration of nonfunctioning parathyroid cysts.
Am Surg, 56 (1990), pp. 420-422
[7]
J.Y. Sung, J.H. Baek, K.S. Kim, D. Lee, E.J. Ha, J.H. Lee.
Symptomatic nonfunctioning parathyroid cysts role of simple aspiration and ethanol ablation.
Eur J Radiol, 82 (2013), pp. 316-320
[8]
M.B. Ujiki, R. Nayar, C. Sturgeon, P. Angelos.
Parathyroid cyst often mistaken for a thyroid cyst.
World J Surg, 31 (2007), pp. 60-64
[9]
A.R. Zambudio, J. Rodríguez, J. Riquelme, T. Soria, M. Canteras, P. Parrilla.
Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery.
Ann Surg, 240 (2004), pp. 18-25
[10]
J.A. Amondarain, X. Aribe, C. Olalla, M. Echenique.
Quiste paratiroideo e hiperparatiroidismo.
Cir Esp, 83 (2008), pp. 97-98
[11]
J.H. Kim.
Ultrasound guided sclerotherapy for benign non thyroid cystic mass in the neck.
Ultrasonography, 33 (2014), pp. 83-90

Please cite this article as: Ruiz J, Ríos A, Rodríguez JM, Parrilla P. Quistes no funcionantes de paratiroides refractarios al tratamiento conservador. Cir Esp. 2018;96:52–54.

Copyright © 2017. AEC
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