Thyroid Nodules 101: Not all nodules in the thyroid gland are thyroid nodules.
1-2 per one hundred have their parathyroid adenoma in the thyroid. US is key. If there is no other
nodules in the neck suspected to be a PA then FNA and PTH washout is the fastest and best way to make sure the “thyroid ” nodule is not a parathyroid adenoma.
Parathyroid scan on left and CT on right.
Ultrasound of a parathyroid adenoma in the thyroid.
This was the only nodule seen in this patient with hyperparathyroidism.
Needle washout during a FNA found high levels of PTH and low levels of thyroglobulin.
This confirmed the location of the PA in the thyroid gland.
Patient had no symptoms associated with a large nodule in the thyroid gland. However the clue the nodule was parathyroid was the abnormal serum calcium and elevated parathyroid hormone. The physicans went for expensive CT scan and parathyroid scan instead of a less expensive way to make the diagnosis. A FNA needle biopsy with a needle washout for PTH could have have made the diagnosis.
Parathyroid adenoma PA inside the thyroid gland occur 1-6% at surgery. With ultrasound nodules in the thyroid can be studied before surgery. The cytology of a PA looks like a thyroid origin. However the PTH washout will be positive for Parathyroid hormone PTH. The usual therapy includes lobectomy.
If a patient has evidence of overactive parathyroid disease, and there is a nodule in the thyroid gland there is the need for biopsy and PTH washout to determine if the nodule is a parathyroid adenoma.
However in 2019 a location in the thyroid gland away from the area of the recurrent nerve can be treated without surgery just like the usual PA located inferiorly with radiofrequency ablation RFA.
This will save the thyroid gland on the side of the intrathyroidal PA from removal and the possible need for thyroid hormone therapy post op.
Call me for details before surgery for parathyroid adenoma to see if you are a candidate for RFA instead of surgery.
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