Large Parathyroid Adenoma in the Thyroid Gland: The Proper Use of Parathyroid Needle biopsy and PTH Needle washout.
The presence of parathyroid disease and a Nodule in the thyroid and no other positive location of the adenoma by Ultrasound or parathyroid scan makes the thyroid nodule suspect. Doing a thyroid biopsy and collecting PTH and Thyroglobulin TG by needle washout can make the diagnosis. When a parathyroid adenoma is suspected the FNA must be done in a gentle fashion. Multiple large needle passes causes fibrosis and make the surgery difficult and even is confused with the rare parathyroid cancer. #27 needle is inserted and without suction or jabbing swirl the needle 360 degrees and remove. Parathyroid adenomas are bloody so a little blood on the needle is what you expect. Make one slide in case it is not a parathyroid and send for needle washout PTH, and TG.
Comments; Many surgeons and endocrinologists do not think about using parathyroid FNA to obtain needle washout for PTH and TG to help in difficult cases. It can find intrathyroidal parathyroid adenomas as in this case, and diagnose co-existent thyroid cancer present in about 5-10% of parathyroid adenomas.
US of large nodule in the thyroid gland
FNA suspicious of follicular neoplasm and suspicious Afirma. No needle washout tests were done for PTH and TG. which would have made the diagnosis BEFORE surgery. PTH washout can be extremely high while TG may be mildly elevated due to the thyroid location and passing through the thyroid tissue to get to the adenoma./Parathyroid adenomas look just like thyroid neoplasms including papillary ca.
The diagnosis however was made at surgery.
Clear cell parathyroid adenoma. Negative TG and positive PTH imumoperoxidase at bottom left..
Cytology may not be helpful with needle washout PTH and TG.