Background: Parathyroid neoplasia is a heterogeneous group of tumors, including parathyroid adenoma (PA), atypical parathyroid tumors (aPTs), and parathyroid carcinoma (PC). Differential diagnosis, especially preoperatively, between parathyroid carcinoma and the other two entities is challenging. The purposes of this study were to highlight the main differences between different parathyroid tumors and to evaluate how combined PC suspicion and intraoperative adjuncts can influence surgical decision-making and outcome-related issues. Methods: We performed a retrospective study of a database of patients diagnosed with parathyroid tumors who underwent surgical treatment at our endocrine surgery referral center between June 2019 and July 2024. Demographic, clinical, biochemical, imaging, intraoperative, immunohistochemical, and follow-up data were analyzed. Results: A total of 83 cases were included in our study, divided for analysis into PA (n = 67), aPT (n = 9) and PC (n = 7) subgroups. The clinical profile of the cohort showed a significant difference (p< 0.05) between the PA, aPT, and PC subgroups regarding the presence of palpable tumors (0% vs. 11.11% vs. 14.29%), both bone and kidney involvement (14.93% vs. 44.44% vs. 85.71%), and extensive disease beyond bone and kidney involvement (4.48% vs. 44.44% vs. 71.43%). PTH levels over five times the normal value were present at significantly different rates (p< 0.001), with higher rates in the aPT and PC subgroups (55.56% and 85.71%, respectively) compared with the PA subgroup (7.46%). Also, a significant difference (p< 0.001) was observed when analyzing extreme albumin-corrected serum calcium elevations over 14 mg/dL, with much higher rates in the PC subgroup (71.43%) compared to PA (1.49%) and aPT (33.33%). On preoperative ultrasonography, a significantly higher number of PCs presented diameters ≥ 3 cm (p< 0.001), depth-to-width ratios (D/W) ≥ 1 (p= 0.003), suspicious delineation (p< 0.001), and suspicious echotexture features (p< 0.001), compared to PAs. On preoperative US performed by the surgeon, suspicious features for thyroid cancer were identified in five more patients compared to the four identified by the initial US evaluation, and all (10.84% of all patients) were confirmed on final histopathology as papillary thyroid cancers. Intraoperatively, a significant difference (p< 0.001) regarding parathyroid macroscopic suspicious features, including adhesions to the thyroid gland, was seen between subgroups. When analyzing only cases withen blocresection, we found that, in all PC cases, a combined preoperative suspicion was present, and in five cases an intraoperative suspicion was raised. Immunohistochemical data showed significantly different median Ki-67 indices between subgroups (1, 2, and 5;p= 0.008) and a different parafibromin staining profile between PC and aPT. Regarding intraoperative neuromonitoring use, a significantly lower incidence of voice changes related to the external branch of the superior laryngeal nerve was observed in the monitoring vs. non-monitoring group (57.14% vs. 12.5%,p= 0.019). Conclusions: Our findings confirm that, in a multimodal and combined diagnostic approach, early pre- and intraoperative PC suspicion can be raised in order to optimize surgical treatment and, thus, favorably influence the outcome. Utilizing all resources available, including intraoperative parathormone determination, laryngeal nerve neuromonitoring, and immunohistochemistry staining, can bring extra benefit to the management of these challenging cases.
背景：甲状旁腺肿瘤是一组异质性肿瘤，包括甲状旁腺腺瘤（PA）、不典型甲状旁腺肿瘤（aPT）和甲状旁腺癌（PC）。甲状旁腺癌与其他两种类型之间的鉴别诊断，尤其是术前鉴别，具有挑战性。本研究旨在阐明不同甲状旁腺肿瘤之间的主要差异，并评估联合术前PC可疑性判断与术中辅助手段如何影响手术决策及预后相关问题。 方法：我们对2019年6月至2024年7月期间在本内分泌外科转诊中心接受手术治疗的甲状旁腺肿瘤患者数据库进行了回顾性研究。分析了人口统计学、临床、生化、影像学、术中、免疫组化及随访数据。 结果：本研究共纳入83例病例，分为PA（n=67）、aPT（n=9）和PC（n=7）三个亚组进行分析。队列的临床特征显示，在可触及肿瘤（0% vs. 11.11% vs. 14.29%）、骨与肾脏同时受累（14.93% vs. 44.44% vs. 85.71%）以及超出骨与肾脏的广泛病变（4.48% vs. 44.44% vs. 71.43%）方面，PA、aPT和PC亚组之间存在显著差异（p<0.05）。PTH水平超过正常值五倍的比例存在显著差异（p<0.001），aPT和PC亚组（分别为55.56%和85.71%）的比例高于PA亚组（7.46%）。此外，在分析白蛋白校正后血清钙极度升高（>14 mg/dL）时也观察到显著差异（p<0.001），PC亚组（71.43%）的比例远高于PA（1.49%）和aPT（33.33%）。术前超声检查显示，与PA相比，PC中直径≥3 cm（p<0.001）、深宽比（D/W）≥1（p=0.003）、可疑边界（p<0.001）和可疑回声结构特征（p<0.001）的比例显著更高。在外科医生进行的术前超声检查中，与初始超声评估发现的4例相比，额外识别出5例具有甲状腺癌可疑特征的患者，所有病例（占所有患者的10.84%）最终组织病理学均证实为甲状腺乳头状癌。术中，各亚组之间在甲状旁腺宏观可疑特征（包括与甲状腺粘连）方面存在显著差异（p<0.001）。仅分析整块切除病例时发现，在所有PC病例中均存在联合术前可疑判断，其中5例还提出了术中可疑判断。免疫组化数据显示，各亚组间Ki-67指数中位数（1、2和5；p=0.008）存在显著差异，且PC与aPT的parafibromin染色模式不同。关于术中神经监测的使用，监测组与非监测组相比，与喉上神经外支相关的声音改变发生率显著更低（57.14% vs. 12.5%，p=0.019）。 结论：我们的研究结果证实，在多模式联合诊断方法中，早期提出术前和术中PC可疑判断，有助于优化手术治疗，从而对预后产生积极影响。利用所有可用资源，包括术中甲状旁腺激素测定、喉返神经监测和免疫组化染色，可为这些具有挑战性病例的管理带来额外益处。
肿瘤(癌症)患者之家