Management Of Primary Hyperparathyroidism Research Articles

An Audit into the Diagnosis and management of primary hyperparathyroidism

An Audit into the Diagnosis and management of primary hyperparathyroidism

High-frequency Multiphase 4DCT for the Detection of Parathyroid Adenomas: A Pictorial Essay.

4-Dimensional computed tomography (4DCT) for the detection of (an) enlarged parathyroid(s) is a commonly performed examination in the management of primary hyperparathyroidism. In our center, we introduced a high-frequency multiphase 4DCT protocol obtaining 16 phases, including 11 different arterial phases. Exposure to this multiphase 4DCT technique is similar to that for classic helical 4DCT. In this pictorial essay we reconstructed our multiphase 4DCT series in the manner of a classic helical 4DCT and compare both techniques. We illustrate how multiphase 4DCT may aid in the detection of parathyroid adenomas. We found 17 out of 19 lesions demonstrating a type A pattern of enhancement, therefore suggesting this pattern could be more prevalent than previously thought. Some parathyroid adenomas may be mistaken for enlarged lymph nodes using classic 4DCT whereas high-frequency multiphase 4DCT can detect a temporary rise in enhancement, thus suggesting the lesions in question to be of parathyroid origin. Smaller lesions may prove more obvious as the difference in enhancement between parathyroid and thyroid can become more prominent.Key PointUsing high-frequency multiphase 4DCT an arterial phase with maximum enhancement of parathyroid tissue can be defined. This phase may aid in the detection of parathyroid adenomas.

Systems-Level Opportunities in the Management of Primary Hyperparathyroidism: An Informatics-based Assessment.

Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed. This work aims to establish a foundation for an electronic medical record-based intervention that would prompt serum parathyroid hormone (PTH) assessment in patients with persistent hypercalcemia and identify care gaps in their management. A retrospective cohort study was conducted in a tertiary academic health system of outpatients with persistent hypercalcemia, who were categorized as having classic or normohormonal PHPT. Main outcome measures included the frequencies of serum PTH measurement in patients with persistent hypercalcemia, and their subsequent workup with bone mineral density (BMD) assessment, and ultimately, medical therapy or parathyroidectomy. Among 3151 patients with persistent hypercalcemia, 1526 (48%) had PTH measured, of whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) PHPT. PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (P < .001). At median 2-year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (P = .003). Of women aged 50 years or older with classic PHPT, 95 (19%) underwent BMD assessment. Of patients with classic or normohormonal PHPT, 919 patients (67%) met consensus criteria for surgical intervention, though only 143 (15%) underwent parathyroidectomy. Within a large academic health system, more than half of patients with confirmed hypercalcemia were not assessed for PHPT, including many patients with preexisting bone disease. Care gaps in BMD assessment and medical or surgical therapy represent missed opportunities to avoid skeletal and other complications of PHPT.

Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims

BackgroundAmong patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored. MethodsPopulation-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models. ResultsAmong 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69–0.74], 0.68 [95% confidence interval 0.61–0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68–0.77], 0.82 [95% confidence interval 0.67–0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57–0.71]), but no difference in odds of parathyroidectomy. ConclusionRacial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.

Primary Hyperparathyroidism in Pregnancy: Literature Review of the Diagnosis and Management.

Background: Parathyroid disease is uncommon in pregnancy. During pregnancy, multiple changes occur in the calcium regulating hormones which may make the diagnosis of primary hyperparathyroidism more challenging. Close monitoring of serum calcium during pregnancy is necessary in order to optimize maternal and fetal outcomes. In this review, we will describe the diagnosis and management of primary hyperparathyroidism during pregnancy. Methods: We searched MEDLINE, CINAHL, EMBASE and Google scholar bases from 1 January 1990 to 31 December 2020. Case reports, case series, book chapters and clinical guidelines were included in this review. Conclusions: Medical management options for primary hyperparathyroidism during pregnancy are severely limited due to inadequate safety data with the various potential therapies available, and surgery is advised during the 2nd trimester of pregnancy in the presence of severe hypercalcemia (calcium adjusted for albumin greater than 3.0 mmol/L (12.0 mg/dL)). Hypercalcemia should be avoided during pregnancy in order to minimize maternal and fetal complications.

Abstract #1003860: Non-operative Management of Primary Hyperparathyroidism: A Learning Experience

Abstract #1003860: Non-operative Management of Primary Hyperparathyroidism: A Learning Experience

4DCT Scanning Technique for Primary Hyperparathyroidism: A Scoping Review.

Objective 4DCT for the detection of (an) enlarged parathyroid(s) is a commonly performed examination in the management of primary hyperparathyroidism. Protocols are often institution-specific; this review aims to summarize the different protocols and explore the reported sensitivity and specificity of different 4DCT protocols as well as the associated dose. Materials and Methods A literature study was independently conducted by two radiologists from April 2020 until May 2020 using the Medical Literature Analysis and Retrieval System Online (MEDLINE) database. Articles were screened and assessed for eligibility. From eligible studies, data were extracted to summarize different parameters of the scanning protocol and observed diagnostic attributes. Results A total of 51 articles were included and 56 scanning protocols were identified. Most protocols use three (n = 25) or four different phases (n = 23). Almost all authors include noncontrast enhanced imaging and an arterial phase. Arterial images are usually obtained 25–30 s after administration of contrast, and less agreement exists concerning the timing of the venous phase(s). A mean contrast bolus of 100 mL is administered at 3-4 mL/s. Bolus tracking is not often used (n = 3). A wide range of effective doses are reported, up to 28 mSv. A mean sensitivity of 81.5% and a mean specificity of 86% are reported. Conclusion Many different 4DCT scanning protocols for the detection of parathyroid adenomas exist in the literature. The number of phases does not appear to affect sensitivity or specificity. A triphasic approach, however, seems preferable, as three patterns of enhancement of parathyroid adenomas are described. Bolus tracking could help to reduce the variability of enhancement. Sensitivity and specificity also do not appear to be affected by other scan parameters like tube voltage or tube current. To keep the effective dose within limits, scanning at a lower fixed tube current seems preferable. Lowering tube voltage from 120 kV to 100 kV may yield similar image contrast but would also help lower the dose.

Pre-Eclampsia Strikes: Could It Be Related This Gland?

Introduction: Primary hyperparathyroidism (PHPT) is rarely diagnosed in pregnancy and if left untreated has the potential to lead to serious maternal and neonatal complications. We describe a case of PHPT with associated complicated pre-eclampsia. Clinical Case29-year-old primigravida admitted at 33 + 6 weeks with fatigue, 10lbs weight gain and elevated BP. Labs revealed potassium 2.9 (3.5-5.2mmol/L), corrected serum calcium (Ca)11.62 (8.4-10.2mg/dL), ionized calcium 1.69 (1.15-1.33mmol/L), PTH 163.9 (15-65pg/mL) and vitamin D 24.6 (30-100ng/mL). Other labs were normal. Urine studies showed 315mg/24h proteinuria and urine calcium of 129.5 mg/24hrs (100-300mg/24hrs). She was started on magnesium sulphate along with labetalol for BP control, given betamethasone for stimulation of fetal lung maturity as well as potassium repletion. Hypercalcemia (HCa) was initially managed with fluids and Lasix intravenously. At 34 + 2 weeks she developed SOB, orthopnea, headaches with new 9lbs weight gain over 5 days and sustained BP elevation. Urgent C-section was done for pre-eclampsia with severe features. Post-operatively, she suffered from postpartum hemorrhage, managed with transfusion of packed red cells and transient placement of a Bakri balloon. Her HCa worsened with Ca 12.56 and cinacalcet was started after delivery. This coincided with gradual improvement of her BP and Ca to 10.8. She declined additional work-up and was discharged in stable condition. Clinical LessonPHPT often goes undiagnosed in pregnancy, with symptoms of fatigue and constipation mimicking common complaints of pregnancy. Studies have also suggested that up to 25% of patients with PHPT during pregnancy present with hypertension and pre-eclampsia and that there is an association between preeclampsia and the presence of parathyroid adenomas. The pathophysiology is unclear but is thought to be due to endothelial dysfunction triggered by hypercalcemia as well as abnormal placentation. No clear guidelines exist for the management of PHPT during pregnancy, with observation and rehydration being the preferred initial options. The use of cinacalcet as well as curative surgical parathyroidectomy when Ca levels persist >11 in the second trimester have also been described. Our patient presented similarly, with severe pre-eclampsia needing urgent C-section, further complicated by persistent severe HCa. Early diagnosis of PHPT, along with treatment including cinacalcet improved her Ca. It is therefore important that PHPT be considered in patients presenting like ours, progressing to severe pre-eclampsia as early reduction of serum calcium may reduce morbidity and mortality. ReferencesMcCarthy, A., Howarth, S., Khoo, S., Hale, J., Oddy, S., Halsall, D., ... & Samyraju, M. (2019). Management of primary hyperparathyroidism in pregnancy: a case series. Endocrinology, diabetes & metabolism case reports, 2019(1).

Management of Primary Hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is the unregulated overproduction of parathyroid hormone (PTH) resulting in abnormal calcium homeostasis. The disease profile has evolved over the last century from symptomatic hyperparathyroidism to asymptomatic hyperparathyroidism. Primary hyperparathyroidism is a biochemical diagnosis. Parathyroidectomy is the only established cure for this disease. Every effort is made to localize the offending gland preoperaively with various imaging modalities. These localization studies along with intraoperative parathormone monitoring will direct the surgeon to either a focused parathyroidectomy or a four gland exploration. All symptomatic patients and asymptomatic patients who meet the criteria for surgery should undergo parathyroidectomy if no medical contraindications exist. Pharmacologic approaches are reserved for those patients unfit or unwilling to undergo surgery.

Detection of parathyroid adenomas with multiphase 4DCT: towards a true four-dimensional technique

BackgroundFour-dimensional computed tomography (4DCT) is a commonly performed examination in the management of primary hyperparathyroidism, combining three-dimensional imaging with enhancement over time as the fourth dimension. We propose a novel technique consisting of 16 different contrast phases instead of three or four different phases. The main aim of this study was to ascertain whether this protocol allows the detection of parathyroid adenomas within dose limits. Our secondary aim was to examine the enhancement of parathyroid lesions over time.MethodsFor this prospective study, we included 15 patients with primary hyperparathyroidism and a positive ultrasound prior to surgery. We performed 4DCT with 16 different phases: an unenhanced phase followed by 11 consecutive arterial phases and 4 venous phases. Continuous axial scanning centered on the thyroid was performed over a fixed 8 cm or 16 cm coverage volume after the start of contrast administration.ResultsIn all patients, an enlarged parathyroid lesion was demonstrated, and the mean lesion size was 13.6 mm. The mean peak arterial enhancement for parathyroid lesions was 384 Hounsfield units (HU) compared to 333 HU for the normal thyroid. No significant difference could be found. The time to peak (TTP) was significantly earlier for parathyroid adenomas than for normal thyroid tissue: 30.8 s versus 32.3 s (p value 0.008). The mean slope of increase (MSI) of the enhancement curve was significantly steeper than that of normal thyroid tissue: 29.8% versus 22.2% (p value 0.012). The mean dose length product was 890.7 mGy cm with a calculated effective dose of 6.7 mSv.ConclusionOur 4DCT protocol may allow better visualization of the pattern of enhancement of parathyroid lesions, as enhancement over time curves can be drawn. In this way, wash-in and wash-out of contrast in suspected lesions can be readily demonstrated. Motion artifacts are less problematic as multiple phases are available. Exposure to our proposed 4DCT technique is comparable to that for classic helical 4DCT. Careful selection of parameters (lowering kV and SNR) can help to further reduce the dose.

Management of Primary Hyperparathyroidism With Severe Hypercalcemia During the COVID-19 Pandemic

PurposeIn patients with primary hyperparathyroidism (PHPT) and severe hypercalcemia, parathyroidectomy remains the only curative therapy. During the coronavirus disease 2019 (COVID-19) pandemic, when many hospital visits are suspended and surgeries cannot be performed, the management of these patients represents a challenging clinical situation. This article presents a literature review and discussion of the pharmacologic management of PHPT and severe hypercalcemia, which can be used as a temporary measure during the COVID-19 pandemic until parathyroidectomy can be performed safely. MethodsThis narrative review was conducted by searching literature on the PubMed, Medline, and Google Scholar databases using the terms primary hyperparathyroidism, hypercalcemia, cinacalcet, bisphosphonates, denosumab, vitamin D, raloxifene, hormone replacement therapy, coronavirus, and COVID-19. FindingsAppropriate monitoring and remote medical follow-up of these patients are essential until the resolution of the pandemic. Cinacalcet is the drug of choice for controlling hypercalcemia, whereas bisphosphonate or denosumab is the drug for improving bone mineral density. Combined therapy with cinacalcet and bisphosphonates or cinacalcet and denosumab should be considered when the effects on serum calcium and bone mineral density are simultaneously desired. ImplicationsMedical management of PHPT and severe hypercalcemia presents a reasonable alternative for parathyroid surgery during the COVID-19 outbreak and should be instituted until the pandemic ends and surgery can be performed safely.

Advances in the diagnosis and the management of primary hyperparathyroidism.

The parathyroid glands, one of the last organs to be discovered, are responsible for maintaining calcium homeostasis, and they continue to present the clinician with diagnostic and management challenges that are reviewed herein. Primary hyperparathyroidism (PHPT) comprises the vast majority of pathology of the parathyroid glands. The classic variant, presenting with elevated calcium and parathyroid hormone levels, has been studied extensively, but the current body of literature has added to our understanding of normocalcemic and normohormonal variants of PHPT, as well as syndromic forms of PHPT. All variants can lead to bone loss, kidney stones, declining renal function, and a variety of neurocognitive, gastrointestinal, and musculoskeletal complaints, although the majority of PHPT today is asymptomatic. Surgery remains the definitive treatment for PHPT, and advances in screening, evolving indications for surgery, new imaging modalities, and improvements in intra-operative methods have greatly changed the landscape. Surgery continues to produce excellent results in the hands of an experienced parathyroid surgeon. For those patients who are not candidates for surgery, therapeutic advances in medical management allow for improved control of the hypercalcemic state. Parathyroid cancer is extremely rare; the diagnosis is often made intra-operatively or on final pathology, and recurrence is common. The mainstay of treatment is normalization of serum calcium via surgery and medical adjuncts.

Management of Primary Hyperparathyroidism.

Since the last international guidelines were published in 2014 on the evaluation and management of primary hyperparathyroidism (PHPT), new information has become available with regard to evaluation, diagnosis, epidemiology, genetics, classical and nonclassical manifestations, surgical and nonsurgical approaches, and natural history. To provide the most current summary of these developments, an international group, consisting of over 50 experts in these various aspects of PHPT, was convened. This paper provides the results of the task force that was assigned to review the information on the management of PHPT. For this task force on the management of PHPT, two questions were the subject of systematic reviews using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The full report addressing surgical and nonsurgical management of PHPT, utilizing the GRADE methodology, is published separately in this series. In this report, we summarize the results of that methodological review and expand them to encompass a much larger body of new knowledge that did not specifically fit the criteria of the GRADE methodology. Together, both the systematic and narrative reviews of the literature, summarized in this paper, give the most complete information available to date. A panel of experts then considered the last set of international guidelines in light of the newer data and assessed the need for their revision. This report provides the evidentiary background to the guidelines report. In that report, evidence from all task forces is synthesized into a summary statement and revised guidelines for the evaluation and management of PHPT. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Management of primary hyperparathyroidism in pregnancy

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Hyperparathyroidism (primary) NICE guideline: diagnosis, assessment, and initial management.

Parathyroid hormone (PTH) is secreted from four parathyroid glands situated behind the thyroid gland. PTH regulates calcium and phosphate levels by its promotion of phosphate excretion and calcium reabsorption in the kidneys; stimulation of osteoclastic activity in the bone resulting in raised serum calcium; and increased intestinal absorption of calcium. Hyperparathyroidism is excessive secretion of PTH and can be primary, secondary, or tertiary: This article summarises the new National Institute for Health and Care Excellence (NICE) guideline for the diagnosis, assessment, and initial management of primary hyperparathyroidism (PHPT).2 This article highlights areas of particular importance for primary care. The causes and management of hypercalcaemia outside of the diagnosis and management of PHPT are beyond the scope of this article. The signs and symptoms of PHPT are predominantly brought about by hypercalcaemia and include thirst, increased …

MON-LB64 Primary Hyperparathyroidism With Severe Hypercalcemia During Pregnancy: A Challenging Diagnosis and Management

Background:Primary Hyperparathyroidism (PHPT) is rare in pregnancy and the physiological adaptations in mineral and skeletal homeostasis that occur during gestation need to be taken into consideration for the diagnosis and management. Clinical case:A 30-year-old primgravid woman with history of kidney stones presented at our institution during the 13th week of twin gestation with severe nausea and vomiting. She had previously been hospitalized at 9 weeks for hypercalcemia and acute kidney injury, and treated with steroids for presumed granulomatous disease without improvement. She was on prenatal vitamins and family history was significant for kidney stones, but not hypercalcemia. At admission, calcium was 14.4 mg/dl, ionized calcium 1.89 mmol/L (1.16-1.32), PTH 15.2 pg/ml (12-88), albumin 3.4 g/dl, phosphorus 2.1 mg/dl, and creatinine 1.8 mg/dl. PTHrP was <2 pmol/L (<4.2) and 1, 25-dihydroxyvitamin D was 191 pg/mL (2nd trimester range 72-160 pg/ml). She was treated with IV hydration, but her calcium remained elevated and severe hypercalcemia recurred after stopping hydration. She underwent neck exploration and right upper parathyroidectomy in the second trimester. The other parathyroid glands were noted to be normal. Intraoperative PTH dropped from 25.2 pg/mL to 4.4 pg/mL. Final pathology showed a hypercellular parathyroid. Her calcium dropped to normal levels in the early postoperative period. Calcitonin was initiated by another provider two weeks postoperatively for persistent mild hypercalcemia. Her calcium levels remained at the upper limit of normal during her 2nd and 3rd trimesters. PTH remained suppressed at 3.2 pg/ml. She had a C-section at 34 weeks for premature rupture of membranes. Her twins did not develop hypocalcemia or hypoparathyroidism. The most recent postpartum calcium was 9.2 mg/dl with PTH 3.3 pg/ml.Conclusions:Our case highlights the challenge in the diagnosis and management of PHPT in pregnancy. During pregnancy, PHPT is diagnosed by elevated ionized or albumin corrected calcium and non-suppressed PTH level. It is important to note that 1,25-dihydroxyvitamin D levels physiologically increase in the second and third trimester. Since both PHPT and pregnancy cause intestinal calcium absorption and bone resorption, PHPT during pregnancy has increased risk of severe hypercalcemia, pancreatitis and renal stones. During the third trimester the transfer of calcium through the placenta and the uptake of calcium by the fetal skeleton can protect against severe hypercalcemia. However, hypercalcemic crisis can occur because of the peak release of PTHrP by the placenta and breasts, or after delivery due to loss of calcium transfer to the placenta. Parathyroidectomy is preferably performed in the second trimester to reduce fetal and maternal complications. After delivery neonatal hypocalcemia can have a delayed onset, a prolonged course and could be permanent.

SUN-376 A Quality Improvement Project on Identification and Management of Primary Hyperparathyroidism in Patients Who Present with Osteoporosis to Reduce Morbidity from Bone Disease

Introduction:Individuals with Primary Hyperparathyroidism (PHPT); a common endocrine disorder are at increased risk of both vertebral and peripheral fractures.Meanwhile Normocalcaemic Primary Hyperparathyroidism (NPHPT),a recognised phenotype of PHPT with a prevalence of 0.4-3.1% in community-based cohorts were anticipated to be milder but most case series documented high rates of osteoporosis, fractures and kidney stones.Objective:We proactively evaluated patients with a new diagnosis of osteoporosis to (a) identify the frequency of hypercalcaemic and normocalcaemic primary hyperparathyroidism in this cohort of patients and (b) to evaluate the benefit of deploying a proactive process for this evaluation as compared to the current arrangement in our Centre of devolving this to the primary care team.Method:This cross-sectional study evaluated 194 patients whom were referred for dexa scan for newly diagnosed osteoporosis between January 2018 and December 2018. Patients whom had a secondary causes of osteoporosis, eGFR<60mls/min, liver and malabsorptive conditions and taking medications that would interfere with bone metabolism were excluded from the study. A recommendation letter was sent to them and their General Practitioner to undertake the following investigations: serum calcium, PTH, phosphate, vitamin D, magnesium, liver function test, full blood count, coeliac screen and thyroid function test. Abnormal blood tests including new diagnosis of primary hyperparathyroidism and vitamin D deficiency were identified and treated accordingly. A second letter and telephone calls were made as a reminder if no response were received within 12 weeks of the first letter.Results:After the first letter, only 83 (34.3%) patients complied with the request for the blood tests. After another 3 months a further 86 patients had the test done while 25(12.9%) did not have the test done despite the reminder.Mean age was 69.72 ± 13.01 and 90.2% were females. The commonest indication for bone density assessment was fragility fracture (46.2%). 69 (35.6%) had spinal, 77 (39.7%) femoral and 9 (4.6%%) wrist osteoporosis. 17(8.8%) patients were detected to have hypercalcaemic and 8(4.73%) patients had normocalcaemic primary hyperparathyroidism. 18(10.7%) patients had vitamin D deficiency and secondary PHPT with half of these patients (9(5.3%)) had severe deficiency (<25 nmol/L).Conclusions:A significant proportion of patients with osteoporosis without prior history of metabolic bone disease had PHPT but the proportion of these having NPHPT is low unlike what is reported in the literature.Proactive assessment of secondary causes is much more effective and should be routinely deployed

Recent advances in the understanding and management of primary hyperparathyroidism.

Primary hyperparathyroidism is a hormonal disorder whose prevalence is approximately 1–2% in the United States of America. The disease has become more recognizable to clinicians in an earlier phase and, at present, patients can be diagnosed with “classic”, “normocalcemic”, “normohormonal”, or “mild, asymptomatic” primary hyperparathyroidism. Surgery, with a focused parathyroidectomy when possible, or a four-gland exploration, is the only way to cure the disease. Cure is determined by use of intra-operative parathyroid hormone monitoring with long-term cure rates ranging from 90–95%. Newer adjuncts to surgery include CT or PET imaging and near-infrared immunofluorescence. This article highlights updates in parathyroid disease and advances in parathyroid surgery; it does not provide a comprehensive summary of the disease process or a review of surgical indications, which can be found in the AAES guidelines or NIH Symposium on primary hyperparathyroidism.

&amp;lt;sup&amp;gt;11&amp;lt;/sup&amp;gt;C-Choline PET/CT in the Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a relative common medical problem caused by the inappropriate secretion of parathyroid hormone (PTH) by one or more parathyroid glands. The diagnosis is established by serum calcium and PTH levels and once the diagnosis is established imaging studies help localize the hyperfunctioning adenoma in preparation for curative surgery. Until now, the imaging studies most commonly utilized in PHPT are ultrasonography and 99mTc-Sesta-methoxyisobutylisonitrile (MIBI) parathyroid scintigraphy. However, these studies often fail to localize the adenoma and inappropriately delay patient referral to a potentially curative surgery. We present the case of a 64-year-old female with symptomatic PHPT who had 3 negative 99mTc-Sestamibi Scans over a period of 5 years who eventually had a PET/CT with 11C-Choline that identified a right lower parathyroid adenoma. She underwent a right lower parathyroidectomy and had a successful outcome. We present a review the current imaging techniques used in the management of PHPT including 99mTc-Sesta-MIBI scintigraphy and its limitations and novel use of PET/CT with 11C-Choline and 18F-Choline in this disease and emphasize the fact that, according to current guidelines, failure to localize the adenoma should not delay referral for curative surgery.

Management of primary hyperparathyroidism in pregnancy

Management of primary hyperparathyroidism in pregnancy