Case of a Parathyroidectomized Patient Observed Longitudinally by Ultrasonography

Abstract

Parathyroid glands enlarge gradually with the progression of secondary hyperparathyroidism. The significance of down-regulation of the 1,25-dihydroxyvitamin D receptor (VDR) in parathyroid glands has been emphasized. Here we report a case in whom the relationship between the growth rates of the parathyroid glands and their VDR content was examined. A 36-year-old man, who had been hemodialyzed for 8.8 years because of chronic renal failure due to chronic glomerulonephritis, developed severe secondary hyperparathyroidism. The first ultrasonographic examination of the parathyroid glands, performed 10 months before parathyroidectomy, revealed that the sizes of the right upper (RU) and left upper (LU) glands were 10 x 8 x 5 and 14 x 10 x 9 mm3, respectively, although the right lower (RL) and left lower (LL) glands were not detected. The second ultrasonographic examination performed 5 days before PTX revealed that the RU gland had enlarged up to 24 x 12 x 10 mm3, while the LU gland remained unchanged at 16 x 9 x 8 mm3. At this time, the sizes of the RL and LL glands were determined only in the longitudinal section to be 10 x 5 and 4 x 3 mm2, respectively. In the excised specimens, the sizes and weights of the RU and RL glands were 25 x 10 x 9 mm3 and 1,950 mg and 17 x 10 x 8 mm3 and 1,160 mg, respectively, while those of the LU and LL glands were 16 x 10 x 7 mm3 and 850 mg and 9 x 8 x 7 mm3 and 350 mg, respectively. Histopathologic study demonstrated that the RU and RL glands exhibited nodular hyperplasia, while the LU and LL glands exhibited diffuse hyperplasia. Using a ligand binding assay, the VDR content of the rapidly growing RU and RL glands were significantly reduced to 32.6 +/- 9.6 and 32.7 +/- 5.2 fmol/mg protein, respectively, as compared to that of the LU gland with no significant proliferating activity (111.8 +/- 0.8 fmol/mg protein). It is of great interest that the smallest LL gland, which showed some proliferating potential in spite of a histologic pattern of diffuse hyperplasia, has a VDR content of 41.0 +/- 2.6 fmol/mg protein. In summary, it was implied from this case that the VDR content in the parathyroid gland might reduce as the growth rate of the parathyroid gland increases and, furthermore, that the VDR content seems to depend to some degree on the histopathologic pattern rather than on gland weight.