Parathyromatosis.

Sir,

I read with great interest an article entitled “Parathyromatosis following endoscopic parathyroid surgery: A rare occurrence” by Aggarwal et al.[1] It is an interesting and unusual case. I would like to congratulate all the authors for reporting such a nice case and indeed an excellent management in such difficult case. However, I have a few observations in this connection which you may find useful. I would also like to add some interesting point about this condition.

The authors had mentioned that index case was the first case of parathyromatosis following endoscopic parathyroidectomy for benign adenoma.[1] I would like to state that such incident had already been reported and diagnosed by fine-needle aspiration cytology coupled with immunohistochemistry.[2] Another case following endoscopic parathyroidectomy was also reported by Wu et al.[3] It has also been mentioned that in the minimally invasive technique, dissection must be performed carefully to avoid nerve injury and rupture of the capsule which can cause parathyromatosis.

A differential diagnosis between parathyroid carcinoma and parathyromatosis can be challenging during surgery. Parathyromatosis usually present as small and numerous nodules and is often surrounded by dense fibrous tissue due to prior operative intervention, which gives the false impression of a parathyroid carcinoma.

Some immunohistochemical studies have been conducted to distinguish parathyroid carcinoma from benign masses. A recent study indicates that molecular profiles of parathyromatosis are similar to those of benign parathyroid tumors concerning expression of parafibromin expression, Rb expression, and galectin-3.[4]

Parathyromatosis shows positivity for neuroendocrine markers chromogranin and synaptophysin and is positive for Parathyroid hormone (PTH) and cytokeratin (CAM 5.2) and negative for thyroid transcription factor-1.[5]

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