Management Of Primary Hyperparathyroidism Research Articles

Ionized vs serum calcium in the diagnosis and management of primary hyperparathyroidism: which is superior?

BackgroundThe diagnosis of primary hyperparathyroidism (PHPT) is based on the presence of an elevated serum calcium level. The study objective was to compare ionized calcium levels to serum calcium levels with respect to parathyroid hormone level (PTH) and several patient outcomes. MethodsThe study population comprised a retrospective cohort of 268 patients with PHPT who underwent primary parathyroidectomy. Serum calcium levels were compared with ionized calcium levels regarding their association with PTH level, presence of multiglandular disease, adenoma size, and extent of neck exploration. ResultsSerum calcium level was correlated with ionized calcium level (R2 = .68, 95% confidence interval [CI], .56 to .79; P < .0001) and PTH was associated with both serum (R2 = .19; 95% CI, .04 to .33; P = .012) and ionized (R2 = .23; 95% CI, .07 to .38; P = .004) calcium levels. Ionized calcium level was a more sensitive indicator of PHPT because there was a greater incidence of ionized calcium being elevated without concordant serum calcium elevation than vice versa (P < .0001). Ionized calcium was also more linearly associated with adenoma size than was serum calcium (P = .0001). There were no differences between serum and ionized calcium levels in predicting the presence of multiglandular disease or the extent of neck dissection. ConclusionsSerum calcium level is an appropriate first-line biochemical test for the diagnosis of PHPT. However, ionized calcium measurements may provide additional benefit in certain cases of PHPT because it is correlated with PTH level and adenoma size, and it may be a more sensitive marker of disease severity than serum calcium.

Management of primary hyperparathyroidism during pregnancy: a case series of the lessons learnt

Primary hyperparathyroidism (PHPT) is a common condition, affecting approximately 1% of the general population. In women of childbearing age, the correct diagnosis and management is particularly important since PHPT is associated with miscarriage, pre-eclampsia, intrauterine growth restriction, preterm delivery and postpartum neonatal hypocalcaemia. We describe a case series of six women diagnosed with PHPT and their management during pregnancy. We discuss the various diagnostic challenges including interpretation of urine calcium to creatinine clearance ratio during pregnancy, the importance of vitamin D replacement during diagnostic work up and the pros and cons of performing surgery during the 2nd trimester of pregnancy.

Medical management of primary hyperparathyroidism

Medical management of primary hyperparathyroidism

Surgical Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disorder in which the inappropriate elevation in serum parathyroid hormone level results in hypercalcemia. Most cases are caused by a single adenomatous parathyroid gland and less than 15% are caused by multiglandular disease. The incidence of PHPT appears to be increasing. More patients are being identified earlier and often before symptoms develop. Parathyroidectomy is the only definitive management; with it, the patient can achieve biochemical homeostasis and symptom relief, and sequelae are prevented. Even for asymptomatic patients with PHPT, there is a growing trend to recommend early surgical intervention. Controversy continues regarding the role of and reliance on various technologies, such as preoperative localization imaging, intraoperative parathyroid hormone level measurements, and minimally invasive surgery. Although both traditional bilateral 4-gland exploration and targeted approaches are accepted surgical techniques, there is a growing trend in unilateral targeted operations often using these technologies. Regardless of surgical approach, the expected success rate is greater than 95%. This article provides an overview of the contemporary surgical management of PHPT.

Anesthetic management of primary hyperparathyroidism: A role rarely noticed and appreciated so far

Endocrine surgeries have been on the rise for the last few years. During surgery, endocrine disorders present unique challenges to the endocrinologist and to the attending anesthesiologist. The endocrine, electrolyte and metabolic disturbances resulting from such disorders can have a profound effect on the normal human physiological milieu. Surgery of parathyroid glands is no exception and is associated with a multiple challenges during pre-, intra-, and post-operative period. Pre-op examination and optimization is essential so as to prevent any intra-op or post-op complications. The most striking electrolyte disturbance during parathyroid surgery is the imbalance of calcium levels in the body and the main emphasis during the entire peri-operative period revolves around the maintenance of normal serum calcium levels. The present article review in depth the various anesthetic considerations and implications during parathyroid surgery with an emphasis on pre-op preparation for elective and emergency surgery.

Surgeon beware: Many patients referred for parathyroidectomy are misdiagnosed with primary hyperparathyroidism

We hypothesized that patients referred for the evaluation and management of primary hyperparathyroidism (pHPT) often do not have pHPT and that they may be harmed by unwarranted parathyroidectomy (PTX). We reviewed all patients who were referred to our endocrine surgery practice between 2008 and 2011 with International Classification of Diseases, Ninth Revision codes for HPT (252.00), benign or malignant parathyroid tumors (227.1, 194.1, respectively), or hypercalcemia (275.42). Patients with renal failure were excluded. Clinical parameters for investigation included age, sex, presentation, laboratories, imaging studies, and referring physician. Three hundred twenty-four patients were referred for pHPT. The diagnosis was confirmed in 265 (82%), of whom 211 (80%) underwent PTX. Misdiagnoses occurred in 60 of 324 patients (19%). Of these, 54 (90%) had secondary HPT and 6 (10%) had hypercalcemia but no pHPT. Before referral, 70% of misdiagnosed patients underwent localizing studies, 57% of which suggested a positive finding. Considerable confusion exists regarding the differentiation of primary and secondary HPT. Surgeons should be cautioned that patients who are referred for parathyroidectomy, even those with complete laboratory and radiographic evaluations, might not have pHPT at all.

Diagnosis and management of primary hyperparathyroidism in Europe

Background: There is continued debate as to the optimal strategy for diagnosis and management of primary hyperparathyroidism (PHPT).Aim: To compare the strategies used for the diagnosis and management of PHPT by physicians in five European countries.Design: Questionnaire-based survey.Methods: Physicians in France, Germany, the UK, Italy and Spain were invited to participate in the survey which was conducted using a web-based interface and were included in the evaluation if they had treated a minimum of four patients suffering from PHPT in the past year.Results: A total of 421 physicians completed the survey. The majority of respondents were endocrinologists (68%) but other specialities included rheumatologists (10.9%), internists (11.8%) and urologists (9.2%). Diagnostic methods were similar across different countries and specialities but there were significant differences in the proportion of physicians who recommended parathyroidectomy in asymptomatic patients with indications for surgery according to the 2002 National Institutes of Health (NIH) consensus conference statement (χ2 = 26.1, P < 0.001). The proportion of patients referred for surgery ranged from 32% in Italy to 66% in Spain with intermediate values in Germany (64%), France (55%) and the UK (53%). Conversely, pharmacological therapy was used most frequently for these patients in Italy (32%) and least frequently in Spain (14%).Conclusion: Significant differences exist in the management of patients with asymptomatic PHPT in countries across Europe who have accepted indications for surgery according to the NIH consensus statement. Further research will be required to explore the reasons for this and to determine if these differences affect the clinical outcome of PHPT.

Cinacalcet in the management of primary hyperparathyroidism

Parathyroidectomy is currently the only curative treatment for primary hyperparathyroidism (PHPT). There are few alternative treatment options in patients who are ineligible for, or unwilling to undergo, surgery and those in whom parathyroidectomy has failed. Current options include the recently approved drug cinacalcet. Cinacalcet is an allosteric modulator of the calcium-sensing receptor, acting to sensitize this receptor to extracellular calcium. Cinacalcet has been found to be effective in reducing or normalizing serum calcium levels in several groups of PHPT patients, including those with mild-to-moderate PHPT, intractable disease, parathyroid carcinoma and multiple endocrine neoplasia Type 1. Cinacalcet slightly reduces parathyroid hormone levels and has no effect on bone mineral density. Cinacalcet is well tolerated when used at low doses, but side effects are not uncommon when relatively high doses are needed to control hypercalcemia. The current evidence indicates that cinacalcet may be of benefit in a wide spectrum of PHPT severities, offering a novel therapeutic option for the control of hypercalcemia in PHPT patients who are not able to undergo parathyroidectomy. It is presently unknown how much of the biochemical benefit of cinacalcet treatment translates into a clinical benefit, particularly in patients with mild-to-moderate hypercalcemia. Moreover, there are no data as to whether long-term treatment with cinacalcet can prevent the complications of PHPT.

Surgical management of primary hyperparathyroidism guided by double-phase Tc-99m-MIBI scintigraphy

Objective The aim of this work was to study the clinicopathological features of cases with primary hyperparathyroidism (PHPT) referred to National Cancer Institute (NCI), Cairo University in the last six years and to study the role of nuclear medicine techniques in the initial diagnosis and preoperative localization directing surgical management of these cases. cases.

Results from a national survey on the management of primary hyperparathyroidism.

Management of primary hyperparathyroidism (PHPT) continues to be challenging. At the Third International Workshop on PHPT, recent data on this disease were reviewed and new clinical recommendations were developed. There are few data on the influence of new guidelines in clinical practice. We designed an online survey that was sent to all Spanish hospital endocrinology services. The questionnaire included 28 questions about diagnosis and management of PHPT. Ninety-nine of 131 sites (76%), giving health coverage to 70% of Spanish population, completed the survey. The reported incidence of PHPT was 9.95/100,000 person-years. Heighty percent of patients were asymptomatic. Each center performed a median (Q1, Q3) of 12 (6, 20) parathyroidectomies/year. The median (Q1, Q3) percentage of curative interventions (at first trial) was 90% (80, 95). The main reasons for not performing surgery were, by decreasing frequency: surgery contraindication, patient's refusal, loss of monitoring, limited surgery experience. Localization techniques were used in 83% of cases. The main criteria for parathyroidectomy in asymptomatic patients were Ca≥2.875 mmol/l (79%), Tscore ≤-2.5 SD at any site (91%), age <50 yr (80%) and glomerular filtration rate <60 ml/min/1.73 m 2 (82%). Minimally invasive surgery was performed in 42% of centers. Frequency of biochemistry and bone density determinations for non-surgically managed patients was in accordance with international guidelines. The clinical practice of Spanish endocrinologists is consistent with the recommendations of the guidelines from the Third International Workshop for the management of PHPT.

Imaging techniques in parathyroid surgery for primary hyperparathyroidism

As more patients present with the incidental diagnosis of primary hyperparathyroidism due to biochemical screening, treatment guidelines have been developed for the treatment of hyperparathyroidism. Management of primary hyperparathyroidism has evolved in recent years, with considerable interest in minimally invasive approaches. Successful localization of the diseased gland(s) by nuclear imaging and anatomical studies, along with rapid intraoperative parathyroid hormone assay, has allowed for focused and minimally invasive surgical approaches. Patients in whom the localization studies have identified single-gland adenoma or unilateral disease are candidates for such focused approaches instead of the traditional approach of bilateral exploration. These imaging techniques have also been critical in the successful management of patients with persistent or recurrent disease.

Update on the use of cinacalcet in the management of primary hyperparathyroidism.

Cinacalcet is an allosteric modulator of the calcium sensing receptor acting to sensitize this receptor to the extracellular calcium. Cinacalcet has been shown to be effective in reducing or normalizing serum calcium levels in several groups of patients with primary hyperparathyroidism (PHPT), including patients with mild to moderate PHPT, intractable PHPT, and parathyroid carcinoma, and in PHPT as a part of multiple endocrine neoplasia type 1. Cinacalcet slightly reduces PTH levels and has no effects on bone mineral density. Cinacalcet at low doses is well tolerated, but side effects are more frequent and severe when relatively high doses are needed to control hypercalcemia. Cinacalcet may be of benefit in a wide spectrum of PHPT severity, offering a novel therapeutic option for the control of hypercalcemia in PHPT patients who are not able to undergo parathyroidectomy. To what extent the reduction of serum calcium particularly in patients with mild to moderate hypercalcemia, translates into a clinical benefit is currently unknown. Moreover, there are no data as to whether long-term treatment with cinacalcet can prevent the complications of PHPT. Finally, more data are needed on the long-term safety of cinacalcet, particularly at the renal level.

Management of primary hyperparathyroidism

Management of primary hyperparathyroidism

Update on Diagnosis and Management of Primary Hyperparathyroidism

Program Description: The diagnosis and management of primary hyperparathyroidism is generally straightforward. Cases referred from endocrinologists for surgery will usually have the classic laboratory findings and the correct diagnosis. An adenoma will be localized by imaging in approximately 80% to 85% of these patients. As increasing referrals are being generated from primary care physicians rather than endocrinologists, surgeons will invariably see only partially worked up patients and diagnostic dilemmas. The first part of this panel, which is composed of expert endocrine surgeons with extensive experience in parathyroid surgery, will address some of the diagnostic challenges and their evaluation. The second portion of the panel will focus on treatment. Minimally invasive parathyroidectomy (MIP) has become the preferred surgical approach for treatment of primary hyperparathyroidism. Localization of an adenoma on preoperative imaging is the key to being able to perform a successful MIP. The panel will discuss pearls and pitfalls in the imaging of parathyroid adenomas, including the use of ultrasound, sestamibi parathyroid scan, and CT scans. Thirdly the panel will present state of the art minimally invasive parathyroidectomy techniques, such as radioguided surgery, lateral approach, performing MIP under local/sedation. Cases will also be presented on how to approach failed explorations. Educational Objectives: 1) Learn pearls and recognize pitfalls of challenging cases of hyperparathyroidism. 2) Understand the principles and techniques of minimally invasive parathyroidectomy. 3) Learn how to improve the yield of preoperative imaging for primary hyperparathyroidism.

Review: New perspectives in the management of primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a biochemical syndrome caused by the inappropriate or unregulated overproduction of parathyroid hormone, Leading to hypercalcae-mia. It was previously considered a relatively rare disorder, with clinical manifestations dominated by renal and/or bone disease. However, in modern times the diagnosis is most frequently recognized coincidentally on biochemical testing in patients evaluated for unrelated complaints. Parathyroidectomy is the only curative treatment for PHPT, with improved outcomes in symptomatic patients following this procedure. However, surgical intervention in patients with no clear clinical features remains controversial. The National Institutes for Health (NIH) have developed consensus guidelines giving specific indications for when surgery is recommended in patients with asymptomatic PHPT. This article examines the impact of treatment on asymptomatic PHPT, focusing on bone disease, neurocognitive function, quality of Life, cardiovascular disease and mortality. Medical treatment options, including bisphospho-nates and cinacalcet, are also discussed.

Primary hyperparathyroidism

Primary hyperparathyroidism (PHPT), a disease that classically manifests with hypercalcemia, bone disease and kidney stones, has over the past few decades changed into an asymptomatic, incidentally discovered condition. Although an exact etiology cannot always be identified, radiation exposure, genetic mutations and, most recently, prolonged vitamin D and/or calcium deficiency have been implicated. This article reviews epidemiology, pathophysiology, possible etiologies, and clinical presentation, as well as recommended approaches to diagnosis and management. The indications for surgery in patients with asymptomatic disease, long-term follow-up, and the treatment of co-existing vitamin D deficiency in patients with PHPT are also discussed. Finally, we briefly review the clinical manifestations and management of PHPT in pregnant women.

Current concepts in the management of primary hyperparathyroidism

Primary hyperparathyroidism is the commonest cause of hypercalcemia in the ambulatory setting. Widespread use of routine laboratory screening has resulted in a large number of patients presenting with subclinical disease. In truly asymptomatic patients, consensus guidelines have been developed to determine which patients need definitive treatment. The most common pathologic finding is parathyroid adenoma, followed by hyperplasia, double adenomas and parathyroid carcinoma. The mainstay of treatment is surgery. While there is still an important role for four gland exploration and evaluation, there is now considerable interest in a more focused surgical approach. This paradigm shift is based on localizing studies that combine sestamibi scanning with anatomic imaging, most commonly ultrasound scanning. A range of minimally invasive approaches have been developed to treat parathyroid adenomas, including unilateral and single gland explorations as well as a number of different endoscopic techniques. Intra-operative rapid parathormone assay has replaced histologic examination as a more effective method to confirm the adequacy of surgery in most cases. Functional localization and exploration using a gamma probe has also been described. The management of patients with persistent or recurrent hyperparathyroidism is difficult and requires a multidisciplinary approach.

Primary Hyperparathyroidism in Patients with Multiple Endocrine Neoplasia Type 1

Primary hyperparathyroidism may occur as a part of an inherited syndrome in a combination with pancreatic endocrine tumours and/or pituitary adenoma, which is classified as Multiple Endocrine Neoplasia type 1 (MEN-1). This syndrome is caused by a germline mutation in MEN-1 gene encoding a tumour-suppressor protein, menin. Primary hyperparathyroidism is the most frequent clinical presentation of MEN-1, which usually appears in the second decade of life as an asymptomatic hypercalcemia and progresses through the next decades. The most frequent clinical presentation of MEN-1-associated primary hyperparathyroidism is bone demineralisation and recurrent kidney stones rarely followed by chronic kidney disease. The aim of this paper is to present the pathomechanism, screening procedures, diagnosis, and management of primary hyperparathyroidism in the MEN-1 syndrome. It also summarises the recent advances in the pharmacological therapy with a new group of drugs—calcimimetics.

Nonoperative management of primary hyperparathyroidism: the exception rather than the rule

The spectrum of classical primary hyperparathyroidism (pHPT) has expanded from a disabling disease to a largely asymptomatic one, leading to considerable uncertainty regarding which patients with pHPT will truly benefit from operative therapy. In the hands of an experienced endocrine surgeon, parathyroidectomy (PTx) is associated with a greater than 95% cure rate and long-term complication rates of less than 5%. We believe that all patients with pHPT should be referred to an experienced endocrine surgeon for consideration of PTx. Furthermore, our preference is to offer surgical intervention to all patients with pHPT who do not have prohibitive medical comorbidities. The purpose of this article is to outline the anticipated benefits of PTx in patients with nonclassical symptoms of pHPT with regard to improvement of the present condition, prevention of future complications or both.

Tratamiento médico del hiperparatiroidismo primario: papel de los calcimiméticos

Primary hyperparathyroidism (PHPT) is a common endocrinological process, characterized by chronic elevation of serum concentrations of calcium and parathyroid hormone (PTH). The only intervention able to cure the disease is parathyroidectomy. However, there are few valid medical alternatives for patients whose PHPT is unresolved by surgery, or in those with contraindications for surgery or who refuse the procedure. The discovery of calcium-sensing receptors (CaSRs), which regulate PTH secretion according to extracellular calcium concentrations, has allowed specific anti-parathyroid drugs called calcimimetics to be designed. Cinacalcet is an allosteric modulator of CaSR that has demonstrated safety and efficacy in controlling serum calcium values and in reducing PTH levels in patients with PHPT. The exact role of calcimimetics in the overall management of PHPT is promising and should be considered in future clinical practice guidelines.