Typifying the Atypical Parathyroid Adenoma

Sir,

It was a pleasure reading this interesting article[1] on an intriguing subject of endocrine science. Furthermore, the authors have done a commendable job in bringing out this multidepartmental study article with meaningful messages from a reputed institute. However, few de facto lacunae prompted me to put forth pertinent queries for clarification. First, I presume clinico-investigative workup for multiple endocrine neoplasia type 1 (MEN1) syndrome (family history, prolactin, etc.,) was performed in this young woman as that does significantly influence long-term prognosis and management. Did you consider now or in the future any MEN1 genetic screening for this case. Second, were there any intraoperative signs of malignancy or atypical features such as local invasion; pericapsular desmoplasia; adhesions; invasion to surrounding structures, thyroid; regional lymphadenopathy because the only de jure criteria for malignancy is locoregional recurrence or metastasis.[2]

Atypical parathyroid adenomas (APAs) are controversial entities with the lack of robust clinical or pathological criteria but projected to have features intermediate on the spectrum of benign to malignant disease.[34] Third, I found flimsy justification in calling this APA with presented data (minimal capsular islands of cells and pleomorphism). Did you contemplate to further qualify the entity with Ki-67 and cyclin D1 expressions though they are again not sacrosanct.[5] What were the proportions of chief cells, oxyphil, clear cells, and fat component in histopathology. Fourth, size of APAs is usually large and occasionally palpable clinically unlike the sonographic size of lesion was very small (1.8 cm × 0.6 cm). Finally, I do agree with the concluding remarks that more than endocrine specialists, it is the general practitioners, general and primary care physicians who need to be aware of the telltale signs of hyperparathyroidism to save the patient from ignominy of its sequelae and metabolic wrath (renal, bone, cardiac, and dysglycemia).