Higher Preoperative Calcium Research Articles

Revision Parathyroid Surgery - Challenges and Considerations in Comparison to Primary Surgery.

Revision parathyroidectomy is made necessary by recurrent or persistent parathyroid disease. This study aimed to identify challenges in revision surgery compared to primary parathyroid surgery. All revision parathyroidectomies performed by one surgeon over a 17-year period were assessed for demographics, imaging, histology, biochemistry, cure rate, gland weight, gland location and gland ectopia, and compared to a series of 100 primary parathyroidectomies. Twenty-eight revision surgical procedures were identified. Sestamibi scanning for gland localisation was superior to ultrasound in both primary and revision surgery. Pre-operative calcium and gland weight were significantly higher in revision cases. There were no significant differences in post-operative calcium levels, pre- or post-operative parathyroid hormone levels, or gland location. 36 per cent of glands excised in revision surgery were ectopic, compared to 25 per cent in primary procedures. The cure rate was significantly lower in revision surgery. Revision parathyroidectomy patients present with higher pre-operative calcium and larger adenomas; the cure rate is significantly lower in these patients.

Hyperparathyroid crisis: Characteristics and outcomes

BackgroundHyperparathyroid crisis (HPTC) is a potentially lethal condition characterized by severe symptomatic hypercalcemia with calcium levels ≥14 mg/dl. We sought to determine the rate of HPTC and how it differs from hyperparathyroidism (HPT) without crisis (HPTWC). MethodsA retrospective review of patients with surgically treated HPT from 1990 to 2022 was completed. ResultsHPTC occurred in 18 (2.4%) of 783 with primary HPT. Patients with HPTC had higher preoperative calcium and parathyroid hormone levels, lower postoperative calcium levels, larger gland weights and higher rates of ectopic glands, carcinoma, recurrence and mortality compared to patients with HPTWC (all p < 0.05). ConclusionsHPTC is a rare condition manifested by severe HPT that is associated with a higher rate of recurrence and mortality compared to HPTWC. HPTC is associated with larger parathyroid glands that are more often ectopic and malignant.

Revision Parathyroid Surgery – Challenges and Considerations in Comparison to Primary Surgery

Abstract Aim Revision parathyroidectomy is made necessary by recurrent and persistent parathyroid disease. The aim of this study was to identify specific challenges in revision surgery compared to primary parathyroid surgery. Methods All revision parathyroidectomies performed by a single surgeon in a tertiary referral centre over a 17- year period were identified. Cases were assessed for: demographics; imaging; histology; biochemistry; gland weight, location, and ectopia; and cure rate. Results were compared to a consecutive series of 100 primary parathyroidectomies. Statistical analysis was performed using SPSS software. Results 28 revision surgeries were identified (18 persistent, 7 recurrent, 3 insufficient data). Demographics were well matched. Ultrasound correctly localised the pathological gland in 18% of revision cases, compared to 37% of primary cases. Technetium-sestamibi scanning correctly localised the pathological gland in 71% of revision cases, compared to 69% of primary cases. Preoperative calcium was significantly higher in revision cases (2.88 vs 2.80, P&amp;lt;0.05). There was no significant difference in post-operative calcium, pre- or post-operative parathyroid hormone levels, or gland location. 37% of glands excised in revision surgery were ectopic, compared to 24% of primary surgeries (P=0.16). Gland weight was significantly higher in revision cases (2758mg vs 1154mg, P&amp;lt;0.05). Cure rate was significantly lower in revision surgery (86% vs 97%, P&amp;lt;0.05). Conclusion In revision parathyroidectomy, patients present with higher pre-operative calcium, larger adenomas, and a trend towards ectopia. Cure rate is significantly lower following revision surgery. Ultrasound is a poor identifier of adenoma presence and location in revision surgery, whereas Technetium-sestamibi scanning is of value in both primary and revision cases.

Double adenoma as a cause of primary hyperparathyroidism: Asymmetric hyperplasia or a distinct pathologic entity?

BackgroundPrimary hyperparathyroidism (PHPT) caused by double adenoma may carry a higher risk of failure to cure. We compared outcomes in single adenoma (SA), double adenoma (DA) and four-gland hyperplasia (HP). MethodsPatients undergoing initial parathyroidectomy for PHPT were categorized by diagnosis. The primary outcome was persistent/recurrent disease postoperatively. ResultsOf 3408 patients, 81.3% had SA, 9.5% had DA, and 9.3% had HP. Rates of persistence/recurrence were 2.9%, 5.3%, and 4.5% in SA, DA, and HP, respectively (p = 0.281). Patients with persistence/recurrence had higher preoperative calcium (11.0 vs 10.7 mg/dl, p = 0.028) and PTH (96 vs 77 pg/ml, p = 0.015), and lower rates of IOPTH normalization (77% vs 96%, p < 0.001). On multivariable analysis, DA was associated with increased risk of persistent/recurrent disease (OR 3.0, p = 0.017). ConclusionsMost patients with DA are cured with removal of two glands, but approximately 5% experience disease persistence/recurrence. Low-normal final IOPTH was associated with lower risk of persistent/recurrent disease.

Racial Disparities in Primary Hyperparathyroidism.

Racial disparities in surgery are increasingly recognized. We evaluated the impact of race on presentation, preoperative evaluation, and surgical outcomes for patients undergoing parathyroidectomy for primary hyperparathyroidism (PHPT). We performed a retrospective cohort study of patients undergoing parathyroidectomy for PHPT at a single center (1997-2015). Patients were classified by self-identified race, as African-American or White. The primary outcome was disease severity at referral. The secondary outcome was completeness of preoperative evaluation. Operative success and surgical cure were evaluated. A total of 2392 patients were included. The majority of patients (87.6%) were White. African-American patients had higher rates of comorbid disease as well as higher preoperative calcium (10.9 vs.10.8mg/dl, p < 0.001) and PTH levels (122 vs. 97pg/ml, p < 0.001). White patients were more likely to have history of bone loss documented by DXA and nephrolithiasis. African-American patients had lower rates of complete preoperative evaluation including DXA scan. Operatively, African-American patients had larger glands by size (1.7 vs. 1.5cm, p < 0.001) and mass (573 vs. 364mg, p < 0.001). We observed similar operative success (98.9 vs. 98.0%, p = 0.355) and cure rates (98.3 vs. 97.0%, p = 0.756). At the time of surgical referral, African-American patients with PHPT have more biochemically severe disease and higher rates of incomplete evaluation. Operative success and cure rates are comparable.

Serum Magnesium Measurements After Parathyroidectomy for Primary Hyperparathyroidism: Should It be Routine?

BackgroundParathyroidectomy is the treatment of choice in primary hyperparathyroidism (PHPT). Following surgery, significant changes in bone and mineral metabolism may follow, but routine magnesium monitoring is not standard practice. The occurrence of significant clinical events linked to hypomagnesaemia in 3 patients after parathyroidectomy led to our evaluation of magnesium levels after surgery for PHPT.MethodsSerum magnesium levels before and after parathyroidectomy for PHPT were prospectively evaluated in a single centre over a year. The incidence and severity of hypomagnesaemia and its correlation with other biochemical variables were assessed.ResultsA total of 138 patients underwent parathyroidectomy for PHPT. Pre-operative and day 1 post-operative serum magnesium levels were available in 57/138 (41.3%) and 99/138 (71.7%) patients, respectively. Serum magnesium decreased significantly after surgery (mean ± SD of 0.85 ± 0.08 and 0.75 ± 0.11 mmol/L, respectively, p < 0.001). On the day after parathyroidectomy, 31/99 (31.3%) patients had hypomagnesaemia (<0.70 mmol/L); in 3 of whom it was severe (<0.50 mmol/L). Patients with hypomagnesaemia had lower pre-operative magnesium (mean ± SD of 0.78 ± 0.06 and 0.87 ± 0.07 mmol/L, p < 0.001), higher pre-operative calcium [median (IQR) of 2.83 (2.71–2.99) and 2.71 (2.63–2.80) mmol/L, p = 0.001] and higher post-operative calcium [median (IQR) of 2.41 (2.30–2.51) and 2.35 (2.28–2.43) mmol/L, p = 0.046] compared to those with normomagnesaemia. In addition, these patients demonstrated higher drop in calcium levels after surgery (0.44 ± 0.20 and 0.35 ± 0.18 mmol/L, p = 0.033). Magnesium levels after surgery correlated positively with pre-operative magnesium (r = 0.561, p < 0.001) and post-operative PTH (r = 0.210, p = 0.037) and negatively with pre-operative adjusted calcium (r = − 0.389, p < 0.001).ConclusionsSerum magnesium decreased significantly following parathyroidectomy for PHPT and nearly a third of patients developed post-operative, mostly mild hypomagnesaemia. Whilst routine serum magnesium measurements could facilitate prompt recognition and treatment of this electrolyte disturbance, further research needs to establish the clinical importance of mild hypomagnesaemia in these clinical settings and, if indicated, to devise optimal treatment strategies.

Factors associated with glomerular filtration rate variation in primary hyperparathyroidism after parathyroidectomy

Background/aimProlonged hypercalcemia impairs renal function, and a reduced glomerular filtration rate (GFR) is typical in advanced primary hyperparathyroidism (PHPT). There are scarce data related to predictors of renal impairment in patients with PHPT. Hence, we aimed to evaluate changes in kidney function in PHPT patients after parathyroidectomy (PTX) and identify factors associated with GFR variation in these patients.Materials and methodsOne hundred and twenty-five patients with PHPT who underwent surgery between 2012 and 2014 were enrolled in the study. Patients were divided into two groups according to GFR values: patients whose GFR was lower than 60 mL/min/1.73 m2 and higher than 60 mL/min/1.73 m2. Demographic and laboratory parameters were compared before and 6 months after parathyroidectomy.Results Prevalence of antihypertensive drug users and patients with renal cysts and parathormone (PTH) and alkaline phosphatase levels were higher in patients with GFR of ≥60 than in GFR of <60 mL/min/1.73 m2 (P < 0.05). Systolic BP, uric acid, and magnesium were decreased in patients with GFR of ≥60, but GFR did not change in the two groups after parathyroidectomy. After parathyroidectomy, calcium and PTH decreased but 25(OH)D3 and phosphorus increased in the two groups. In multiple regression analysis, age, calcium, and baseline GFR were independent predictors of GFR variation. Parathyroid adenoma volume and urinary calcium were not independent predictors of GFR change.ConclusionOlder age, higher preoperative calcium, and GFR were factors associated with GFR increase in PHPT patients after parathyroidectomy. Further renal impairment was prevented by parathyroidectomy in PHPT patients.

Assessing the risk of hypercalcemic crisis in patients with primary hyperparathyroidism

BackgroundHypercalcemic crisis (HC) is a potentially life-threatening manifestation of primary hyperparathyroidism (PHPT). This study aimed to identify patients with PHPT at greatest risk for developing HC. MethodsThis retrospective cohort study included patients with a preoperative calcium of at least 12 mg/dL undergoing initial parathyroidectomy for PHPT from 11/2000 to 03/2016. We compared those with HC, defined as needing hospitalization for hypercalcemia, to those without HC. ResultsThe study cohort included 29 patients (15.8%) with HC and 154 patients (84.2%) without HC. Demographics and comorbidities were similar between the groups. Patients with HC were more likely to have a history of kidney stones (31.0% versus 14.3%, P = 0.039), higher preoperative calcium (median 13.8 versus 12.4 mg/dL, P < 0.001), higher parathyroid hormone (PTH) (median 318 versus 160 pg/mL, P = 0.001), and lower vitamin D (median 16 versus 26 ng/mL, P < 0.001) than patients without HC. Cure rates with parathyroidectomy were similar, but nearly double the proportion of patients with HC had multigland disease (24.1 versus 12.3%, P = 0.12). In multivariable analysis, higher preoperative calcium (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.5), higher PTH (OR 1.0, 95% CI 1.0-1.0), and kidney stones (OR 3.0, 95% CI 1.1-8.2) were independently associated with HC. A Classification and Regression Tree revealed that HC developed in 91% of patients with a calcium ≥13.25 mg/dL and a Charlson Comorbidity Index ≥4. ConclusionsThese data indicate that calcium, PTH, and kidney stones are important in predicting who are at greatest risk of HC. The Classification and Regression Tree can further help stratify risk for developing HC and allow surgeons to expedite parathyroidectomy accordingly.

Delayed Calcium Normalization After Presumed Curative Parathyroidectomy is Not Associated with the Development of Persistent or Recurrent Primary Hyperparathyroidism.

Following parathyroidectomy for primary hyperparathyroidism (pHPT), serum calcium levels typically normalize relatively quickly. The purpose of this study was to identify potential factors associated with delayed normalization of calcium levels despite meeting intraoperative parathyroid hormone (IOPTH) criteria and to determine whether this phenomenon is associated with higher rates of persistent pHPT. This was a retrospective review of 554 patients who underwent parathyroidectomy for sporadic pHPT from January 2009 to July 2013. Patients who underwent presumed curative parathyroidectomy and had elevated POD0 calcium levels (>10.2mg/dL) were matched 1:2 for age and gender to control patients with normal POD0 calcium levels. Of the 554 patients, 52 (9%) had an elevated POD0 Ca (median 10.7, range 10.3-12.2). Compared with the control group, these patients had higher preoperative calcium (12 vs. 11.1, p<0.001) and PTH (144 vs. 110pg/mL, p=0.004) levels and lower 25OH vitamin D levels (26 vs. 31pg/mL; p=0.024). Calcium normalization occurred in 64, 90, and 96% of patients by postoperative days (POD) 1, 14, and 30, respectively. There was no difference in rates of single-gland disease or cure rates between the groups. After presumed curative parathyroidectomy, nearly 10% of patients had transiently persistent hypercalcemia. Most of these patients had normal serum calcium levels within the first 2weeks and did not have increased rates of persistent pHPT. Immediate postoperative calcium levels do not predict the presence of persistent pHPT, and these patients may not require more stringent follow-up.

Pre-opereative Parathormone Levels are Correlated with Mean Diameter of Parathyroid Adenoma and Pre-operative Serum Calcium and Alkaline Phosphatase Levels

Abstract The aim of the present study was to determine the relationship between biochemical parameters, mean diameter of parathyroid adenoma (MDPA) and parathyroid hormone (PTH) levels in patients who underwent parathyroid surgery.Materials and Methods: Data were collected retrospectively from patients with hyperparathyroidism who were operated and followed in our hospital between September 2011 and April 2014. Twenty-nine (male/female = 8/21) patients with a mean age of 58.31 ± 12.59 years were enrolled into the study. The mean pre-operative serum calcium and intact PTH (iPTH) levels were 11.98±1.23 mg/dl and 386.52±374.96 pg/ml, respectively. Serum pre-operative calcium levels were found to be significantly higher in patients who had nephrolithiasis than those who did not, whereas pre-operative serum phosphate levels were lower. Pre-operative iPTH levels were found to be correlated with pre-operative calcium, alkaline phosphatase and MDPA but not with pre-operative serum phosphate. Also, pre-operative calcium levels were found to be significantly correlated with MDPA.Conclusion: Presence of nephrolithiasis is associated with higher pre-operative calcium and lower phosphate levels. Pre-operative iPTH and calcium levels were also found to be significantly correlated with MDPA; this suggests that serum iPTH and calcium levels can be useful in predicting MDPA. Keywords: Hypercalcemia, primary hyperparathyroidism, parathyroid adenoma, parathormone, calcium

Differences between sporadic and MEN related primary hyperparathyroidism; clinical expression, preoperative workup, operative strategy and follow-up

BackgroundPrimary hyperparathyroidism (PHPT) is most commonly sporadic (sPHPT). However, sometimes PHPT develops as part of multiple endocrine neoplasia (MEN) type 1 or 2A. In all, parathyroidectomy is the only curative treatment. Nevertheless, there are important differences in clinical expression and treatment.MethodsWe analyzed a consecutive cohort of patients treated for sporadic, MEN1-related, and MEN2A-related PHPT and compared them regarding clinical and biochemical parameters, differences in preoperative workup, operative strategies, findings, and outcome.ResultsA total of 467 patients with sPHPT, 52 with MEN1- and 16 with MEN2A-related PHPT were analyzed. Patients with sPHPT were older, more often female and had higher preoperative calcium and parathyroid hormone levels, when compared with MEN1 and MEN2A patients. Minimally invasive parathyroidectomy (MIP) was performed in 367 of 467 sPHPT patients (79%). One abnormal parathyroid was found in 426 patients (91%). Two or more in 35 patients (7%). In six patients (1%) no abnormal parathyroid gland was retrieved. Of 52 MEN1 patients, eight (15%) underwent a MIP and 44 patients (85%) underwent conventional neck exploration (CNE); with resection of fewer than 3½ enlarged glands in 21 patients (40%), subtotal parathyroidectomy (SPTX, 3-3½ glands) in seventeen (33%) and total parathyroidectomy with autotransplantation (TPTX) in six (12%). Eleven patients (21%) had persistent disease, 29 (56%) recurrent PHPT and nine (17%) permanent hypoparathyroidism, mostly after TPTX. Of 16 MEN2A patients, six (38%) underwent MIP, four (25%) CNE and six (38%) selective resection of the enlarged gland(s) during total thyroidectomy. Three patients (19%) suffered from persistent PHPT and two (13%) developed recurrent disease.ConclusionsSporadic PHPT, MEN1- and MEN2A-related PHPT are three distinct entities as is reflected preoperatively by differences in gender, age at diagnosis and calcium and PTH levels.MEN2A patients are very similar to sPHPT with respect to operative approach and findings. MIP is the treatment of choice for both. MIP has low rates of persistent and recurrent PHPT and a low complication rate. The percentage of multiglandular disease and recurrences are significantly higher in MEN1 patients, demonstrating the need for a different approach. We advocate treating these patients with CNE and SPTX.