Resection Of Parathyroid Adenoma Research Articles

Occurrence of parathyroid carcinoma following parathyroid adenoma resection.

Occurrence of parathyroid carcinoma following parathyroid adenoma resection.

Intraoperative video captured with Stryker SPY-PHI system in white light, green overlay, and greyscale fluorescence modes. Procedure performed: resection of parathyroid adenoma from left carotid sheath.

Intraoperative video captured with Stryker SPY-PHI system in white light, green overlay, and greyscale fluorescence modes. Procedure performed: resection of parathyroid adenoma from left carotid sheath.

Pheochromocytoma associated with primary hyperparathyroidism and type 1 neurofibromatosis

Neurofibromatosis type 1 (NF-1) is a predominantly inherited genetic disease with prevalence of 1 per 2500-3000 newborns and based on clear clinical criteria. In addition to common neurofibromas and gliomas of the visual pathways, these patients have a higher risk of various benign and malignant tumors throughout their lives including tumors of the central nervous system, membranes of peripheral nerves, gastrointestinal stromal tumors and leukemia. Endocrine diseases and neoplasms also occur in patients with NF-1 and can include extrarenal paraganglioma, primary hyperparathyroidism, gastroenteropancreatic neuroendocrine tumors, thyroid tumors and other adrenal neoplasms. We demonstrate multiple neuroendocrine neoplasia (MEN 2A) of neurofibromatosis type 1 combined with pheochromocytoma and primary hyperparathyroidism in a woman with a long history of palpitations, paroxysmal hypertension and osteoporosis. Biochemical analysis revealed severe hypercalcemia with elevated parathyroid hormone indicating primary hyperparathyroidism, as well as high fractionated normetanephrine and metanephrine in the urine as a sign of catecholamine-releasing pheochromocytoma/paraganglioma. Further scintigraphy revealed signs of solitary parathyroid adenoma causing primary hyperparathyroidism and right-sided pheochromocytoma. Clinical diagnosis of MEN-2 syndrome is based on combination of at least two major MEN-2-associated endocrine tumors. Resection of parathyroid adenoma and pheochromocytoma normalized biochemical parameters and blood pressure. Combination of pheochromocytoma with primary hyperparathyroidism and type 1 neurofibromatosis is discussed.

PSAT219 Renal Phosphate Wasting Caused by ENPP-1 mutation.

Abstract Background Increased renal phosphate loss can be Fibroblast Growth Factor-23 (FGF-23) dependent or independent. FGF-23 reduces expression of Sodium-Phosphate co-transporters, responsible for phosphate reabsorption; and by inhibition of 1-alpha hydroxylation of 25-OH-D3. Reduced serum concentration of 1, 25-OH2-D3 results in secondary hyperparathyroidism. Ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) mutation is one of the rarest causes of hypophosphatemia, which causes FGF-23 dependent hypophosphatemia. Case description 31-year-old female referred to endocrinology for evaluation of recurrent nephrolithiasis despite normalization of PTH and serum Calcium (Ca) after right inferior parathyroid adenoma resection. Repeated renal stone analysis revealed calcium phosphate as the major stone composition. Patient achieved mid parental height, denied history of calcium or phosphate metabolism disorders/ rickets in the family. Physical exam was not suggestive of rickets and skeletal survey showed normal bone mineralization. Initial labs following parathyroid adenoma resection showed normal Ca 9.7 mg/dl, PTH 47 pg/ml, Phosphorus (Ph) 2.3 mg/dl, 25-OH-D3 51 ng/ml, albumin 3.9 g/dl, Mg 1.8 mg/dl. Repeat fasting labs six months later revealed Ca 9 mg/dl, Ph 1.7 mg/dl, 25-OH-D3 52 ng/ml, PTH 67.5 pg/ml and albumin 3.7 g/dl. Persistent low serum phosphate was evaluated further by a 24-hour urine collection which revealed high urine phosphate of 828 mg/day, Ca 181 mg/day, Mg 23 mg/day and creatinine was 1485 mg/day. Tubular reabsorption of phosphorus was 77% (normal: >80%), indicating renal phosphate wasting. Serum FGF-23 on two different days was >180 RU/ml. Next-generation sequencing tested positive for heterozygous ENPP-1 gene mutation variant c1441C>T (p. Arg481Trp). Patient was started on oral Phosphorus supplementation & calcitriol. Repeat labs showed normalization of Ph 2.4 mg/dl. Audiology evaluation suggested mild sensorineural hearing loss. Heart calcium score was zero. Discussion ENPP1 gene mutation's clinical presentations can vary from no symptoms, hypophosphatemic rickets to death in the first six months of life from generalized arterial calcification. ENPP1 is an enzyme, which degrades ATP into adenosine monophosphate (AMP) and pyrophosphate (PPi). PPI is an inhibitor of hydroxyapatite crystallization in vascular tissue and organs, while Ph is a pro-mineralization factor. ENPP1 gene mutation results in a low concentration of PPi, predisposing the patient to pathological calcification. It is speculated that ENPP-1 modulates FGF-23 secretion. FGF-23 elevation in these patients is a protective response, as hypophosphatemia prevents pathological calcification. Treatment target is to keep phosphate at low end of normal. In our patient, ENPP- 1 mutation likely contributed to recurrent renal stones and possible parathyroid adenoma. Evaluation of genetic mutations is necessary to decide for or against FGF-23 antibody/Burosumab treatment. In ENPP-1 mutation. Burosumab should be avoided as it can bind to FGF-23 resulting in pathological calcification. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Innovative Approach of Endosonographic Radioactive Labeling of an Ectopic Parathyroid Adenoma by Technetium-99m Human Serum Albumin: A Case Report

Primary hyperparathyroidism caused by parathyroid adenoma requires surgical resection. To confine the extent of surgery to the very minimum and to exclude an atypical adenoma location, preoperative imaging aims at identifying the suspicious gland. For this purpose, Technetium-99m (99mTc)-sestamibi scintigraphy and SPECT have become the international imaging standard, in inconclusive cases also with C-11 methionine and F-18 choline PET/CT. We present a case of surgery for an ectopic retroesophageal adenoma resected under gamma probe guidance after preoperative radioactive targeting. A 73-year-old patient, who was diagnosed with primary hyperparathyroidism, presented to our outpatient clinic. The patient was symptom-free, but during a routine check-up, parathormone levels of 127 pg/ml (normal range 15-65) were detected. Parathyroid MIBI scintigraphy, including SPECT/CT, failed to locate an adenoma. Therefore, a PET/MRI scan with 164 MBq F-18 choline was applied and a single parathyroid adenoma was detected in a very untypical retroesophageal and prevertebral position, respectively. Due to its esophageal proximity and to enable a very confined surgery, endosonography was performed and the adenoma was transesophageally injected with 75 MBq 99mTc-human serum albumin (HSA). The next day gamma probe-guided minimally invasive resection was performed without any intra- or postoperative complications. Minimally invasive resection of parathyroid adenomas should be the standard but may be difficult in deep collar and atypical locations. Marking the adenoma with a radioactive nanocolloid tracer for gamma probe-guided surgery can be considered an innovative approach to maintain minimal invasive therapy for ectopic adenomas.

Severe Refractory Hypocalcemia After Administering Zoledronic Acid for Osteoporotic Fracture in Primary Hyperparathyroidism That Is Complicated Into Hungry Bone Syndrome: A Case Report

Zoledronic acid is a very effective (IV) amino bisphosphonate which is indicated in osteoporosis, hypercalcemia of malignancy, multiple myeloma, Paget’s disease, and bone metastases from solid tumors. Bisphosphonate inhibits bone resorption through actions on osteoclast activity resulting in increasing bone density. Unfortunately, there are side effects associated with zoledronic acid one of those is mild to moderate hypocalcemia. Hungry Bone Syndrome (HBS) is defined as a severe drop in calcium levels less than 2.1 mmol/L and/or prolonged hypocalcemia for more than 4 days post parathyroidectomy. Most seen in patients’ who have secondary hyperparathyroidism compared to primary hyperparathyroidism. The sudden drop of parathyroid (PTH) levels post parathyroid resection after a prolonged duration of high PTH levels causes net calcium to move into the bone, this is the most proposed hypothesis. The authors report a case of a 32 years old female known case of severe osteoporosis presented to the emergency department complaining of left hip pain after a short height fall admitted as a case of pathological fracture. Furthermore, upon admission was vitally stable although on examination the patient had left side hip pain and tenderness otherwise unremarkable. Initial lab investigation showed a calcium level of 2.57 mmol/L and PTH level 37 pmol/L otherwise electrolytes and full blood count were unremarkable. Radiological investigations were done, and an X-ray has shown a left hip fracture where the patient underwent an operating room for fixation. In addition, a 99mTc-HDP bone scan revealed hyperparathyroidism and brown tumor. 99m Tc SESTA-MIBI whole body scan suggested metabolic bone disease. Furthermore, the parathyroid showed suggested typical parathyroid adenoma below and lateral to the lower pole of the left thyroid lobe. The ultrasound of the thyroid showing a well-defined hypoechoic nodule 2.5x1.15 cm with significant hypervascularity is seen, which is most likely to be enlarged left parathyroid gland. Thus, diagnosis of primary hyperparathyroidism has been reached with parathyroid adenoma which was resected during a hospital stay. The patient received pre-op zoledronic acid as a treatment for osteoporosis prior to the hip operation. After the parathyroid adenoma resection, the patient had a sudden drop of PTH and developed hypocalcemia which was 1.1 mmol/L. Thus, the complication of post operated parathyroid adenoma of HBS diagnosis has been made. Interestingly the patient needed to increase the length of stay of the hospital due to refractory hypocalcemia where the patient has been receiving IV calcium and vitamin D supplementation which hadn’t improved until a month of IV calcium gluconate. Although, the patient didn’t develop any signs or symptoms of hypocalcemia.

What to do when the parathyroid gland is not found during a transcervical exploration?

The most frequent cause of suboptimal results in a parathyroid adenoma resection is an ectopic location, mainly in the anterior mediastinum. These cases may not always be resected through a traditional cervical access. We present 2 cases of primary hyperparathyroidism who underwent an unsuccessful bilateral cervical exploration due to parathyroid tissue located inside the thymic gland. A video-assisted thoracoscopic surgery thymectomy with intraoperative determination of blood parathormone levels was performed. A 50% reduction of intraoperatory parathyroid hormone blood from the highest basal level at 5 and 10 min after resection was obtained. Final pathological results showed an intra-thymic parathyroid adenoma in the first patient and an intra-thymic focus of parathyroid hyperplasia in the second patient. In conclusion, video-assisted thoracoscopic surgery thymectomy could be the optimal approach to resect ectopic parathyroid adenomas located in the anterior mediastinum.

Single Center Experience in the Surgical Management of Primary Hyperparathyroidism.

Objectives.As calcium included as a part of routine laboratory screening early diagnosis of primary hyperparathyroidism (PHPT) has been increased. Surgical resection of parathyroid adenoma or hyperplasia still is the mainstay of the treatment for most PHPT patients. The aim of this study was to evaluate of the surgical outcomes of patients with PHPT that referred to our ENT department of our University Hospital for the last 6 years.Methods.One hundred thirty-seven patients with PHPT who underwent parathyroid surgery in our clinic between October 2011 and January 2018 included in this retrospective study. Data on demographics, clinical findings, past medical history, preoperative laboratory values in 3 months, preoperative localizing imaging studies including ultrasonography (USG) and 99mTc-sestamibi (methoxyisobutyl isonitrile, [MIBI]) scan, operative findings, postoperative laboratory values, and pathology reports were recorded. MIBI scan and USG are used as the first-line modalities in our center. Single-photon emission computed tomography was used for challenging situations of re-exploration and ectopic parathyroid pathology. Four-dimensional computed tomography scanning is was preferred as the last imaging modality. Focused unilateral neck exploration (FUNE) was performed with intraoperative frozen section analysis as a routine procedure. Bilateral neck exploration (BNE) was used only in re-exploration, ectopic parathyroid, and with high suspicion of multigland disease.Results.Totally 137 patients (female:male, 3:3; mean age, 54.6±13.2 years) included in the study. Single parathyroid adenoma was found in 108 patients (78.8%). Most common adenoma localization was left inferior parathyroid gland (46.7%). FUNE was performed in 89.8% of the patients and BNE for 10.2% of the patients. Postoperative normocalcemia was reached in 132 patients and permanent hypocalcemia was observed in two patients. Persistence hypercalcemia observed in three patients. Postoperative pathology reports revealed three patients have parathyroid carcinoma.Conclusion.Preoperative imaging modalities is very important in parathyroidectomy surgery. Routine use of preoperative imaging modalities reduced the risk of complications in our clinic.

Repeated epistaxis caused by primary hyperparathyroidism with multiple brown tumors: One case report

To report the clinical, imaging and pathological feature of a case of primary hyperparathyroidism(PHPT) with multiple brown tumors whose complain was repeated epistaxis, and to conduct a retrospective analysis with relevant literatures. A postmenopausal middle-aged woman, with a history of joint pain, fracture, and kidney stone which were neglected due to the lack of specificity of symptoms for years, went to hospital due to repeated epistaxis. Laboratory results showed high blood calcium, hypophosphatemia, alkaline phosphatase(ALP), and parathyroid hormone(PTH) levels, as well as increased urinary calcium. Imaging examination showed systemically multiple brown tumors and extensive osteoporosis. Meanwhile an abnormal mass was found behind the right thyroid. Taking all findings into account, the diagnosis was made with PHPT, and the histopathology further confirmed that the lesion was a parathyroid adenoma. This case seems to be a rare case of multiple brown tumor caused by parathyroid adenoma, which compressed and destructed nasal blood vessels, thus induced a repeated nasal discharge. After resection of parathyroid adenoma, the patient experienced a transient hypocalcemia and PTH level elevation. After 5-month follow up, part of the brown tumors spontaneously regressed, bone density increased, and her clinical symptoms were mostly relieved. Key words: Primary hyperparathyroidism; Parathyroid adenoma; Brown tumor; Epistaxis

Ambulatory surgery under local anesthesia for parathyroid adenoma: Feasibility and outcome

Outpatients undergoing parathyroid adenoma resection by a focused approach under LA were included. Results were evaluated by intraoperative serum parathormone levels (ioPTH) and the balance of phosphate and calcium postoperatively, at 3 months, 1 year and at the point date. The quality of ambulatory care was evaluated by the number of cancelled interventions, the number of patients hospitalized after surgery or during the first postoperative month. The patient data manager of the institution carried out a medico-economic analysis. From 2005 to 2014, 129 patients met the inclusion criteria [women: 82% (sex ratio 1:5), median age: 72 years]. There was no morbidity for 98% of patients. Twelve patients had no statistically significant drop in ioPTH: two had persistent primary hyperparathyroidism (PHP). LA failed in four patients and PTH was late to normalize in six patients. Six patients had recurrent PHP (4.6%), of which two occurred four years after excision. Outpatient treatment was successful in 95%, without deprogramming or rehospitalization. The cost of the treatment under LA and on an outpatient basis was € 2014.90 (vs. € 2581.47 under general anesthesia and traditional hospitalization) CONCLUSION: Excision of single parathyroid adenomas can be performed under LA in an ambulatory setting without any major risk for the patient. The risk of recurrence after the focused approach requires regular laboratory monitoring for at least five years.

Radio-guided Minimally Invasive Parathyroidectomy: A Descriptive Report of the Experience from Tertiary Center in Bangalore.

Overview:Minimally invasive parathyroidectomy (MIP) is an accepted surgical procedure for parathyroid adenomas. In the patients with parathyroid adenoma localized by dual phase 99mTc-Sestamibi scan, a focused approach utilizing the gamma probe intra-operatively helps in ensuring complete resection and avoiding exploration of the other parathyroid glands.Objective:The aim of the study was to evaluate the performance of radio-guided MIP for parathyroid adenomas detected by dual phase 99mTc-MIBI preoperatively, without intra-operative parathyroid hormone (ioPTH) monitoring for patients who had evidence of single-gland disease.Patients and Methods:A retrospective dataset of 30 patients diagnosed with solitary parathyroid adenoma operated between 2009 and 2014 were reviewed. All of the patients underwent radio-guided MIP and were followed up for at least 6 months post-operatively. The biochemical parameters (serum calcium and serum parathyroid hormone levels), imaging parameters (ultrasonography and 99mTc-MIBI), and operative times were analyzed.Results:Our study consisted of 30 patients with 50% females, with a mean age of 42.5 + 12 years. The mean surgical duration was 20 + 12 min. All of the patients achieved biochemical cure (normalization of serum calcium) and remained eucalcemic at follow-up. No major surgical complications were noted.Conclusions:Focused parathyroidectomy using the gamma probe localization could be a potential alternative for ioPTH assay in ensuring the completeness of surgical resection of parathyroid adenoma. It is also likely to shorten operative time.

Atypical Cystic Parathyroid Adenoma Masquerading as a Thyroid Nodule and Presenting with Severe Hypercalcemia

Background: Primary hyperparathyroidism occurs as a result of isolated parathyroid adenoma in 80% to 85% of all cases. Severe hypercalcemia due to cystic atypical parathyroid adenoma is rare entity. Method: We report a rare case of severe hypercalcemia associated with cystic atypical parathyroid adenoma. Result: 27 year old female presented with nausea, vomiting and abdominal pain. A serum calcium level of 15.8 mg/dl with PTH of 413 was noted on admission. She was initially treated with IV hydration and had ultrasound of neck which showed 2.8 cm complex nodule in right thyroid lobe. After appropriate work up, she underwent a surgical resection of parathyroid adenoma found on CT with 3D reconstruction. Pathology showed a mixed picture more consistent with possible atypical adenoma. Conclusion: Parathyroid cyst is known but rare entity, which is usually nonfunctional. However, atypical cystic parathyroid adenoma with severe hypercalcemia is very rarely reported. It may exhibit some pathologic features of carcinoma, but angio-invasion and/or metastases are not present. Severe hypercalcemia with a large, cystic neck mass should prompt thoughts of cystic atypical parathyroid adenoma versus carcinoma. In both cases, long-term follow up would be prudent. Also, our case emphasizes the importance of knowing ultrasonographic features to differentiate parathyroid adenoma appearing as thyroid nodule.

Video assisted thoracoscopic excision of mediastinal ectopic parathyroid adenomas: a UK regional experience.

To report the first series of video-assisted thoracoscopic surgery (VATS) resection of mediastinal ectopic parathyroid adenomas (MEPAs) in the UK. A case series of seven cases undergoing VATS between 2004 and 2009 to treat single gland hyperparathyroidism. Methylene blue (MB) was used in 5/7 cases immediately before exploration to identify the adenomas. Carbon dioxide (CO2) up to pressures of 10 mmHg was used safely to deflate the lung in two cases. There were five women and two men with a mean age of 53 years (range, 27-72 years). Histopathology confirmed successful resection of the parathyroid adenoma in 6/7 cases. There was one conversion to open thoracotomy due to bleeding from the azygos vein resulting from excessive traction. Despite marked MB uptake, this patient proved to have tuberculoid adenopathy and no parathyroid tissue was identified. Postoperative plasma calcium returned to normal in 6/7 patients and parathyroid hormone (PTH) level in 6/7 patients. The median hospital stay was 2 days and there was no mortality in this series. MEPAs can be safely resected using VATS with minimal surgical morbidity, short drainage time and short hospital stay. CO2 insufflation and the intraoperative use of MB are safe and help to accurately localise the ectopic adenoma. VATS should be considered as the first-line approach for resection of MEPAs.

Intraoperative scintigraphy using a large field-of-view portable gamma camera for primary hyperparathyroidism: initial experience.

Background. We investigated a novel technique, intraoperative 99 mTc-Sestamibi (MIBI) imaging (neck and excised specimen (ES)), using a large field-of-view portable gamma camera (LFOVGC), for expediting confirmation of MIBI-avid parathyroid adenoma removal. Methods. Twenty patients with MIBI-avid parathyroid adenomas were preoperatively administered MIBI and intraoperatively imaged prior to incision (neck) and immediately following resection (neck and/or ES). Preoperative and intraoperative serum parathyroid hormone monitoring (IOPTH) and pathology (path) were also performed. Results. MIBI neck activity was absent and specimen activity was present in 13/20 with imaging after initial ES removal. In the remaining 7/20 cases, residual neck activity and/or absent ES activity prompted excision of additional tissue, ultimately leading to complete hyperfunctioning tissue excision. Postexcision LFOVGC ES imaging confirmed parathyroid adenoma resection 100% when postresection imaging qualitatively had activity (ES) and/or no activity (neck). The mean ± SEM time saving using intraoperative LFOVGC data to confirm resection versus first IOPTH or path result would have been 22.0 ± 2 minutes (specimen imaging) and 26.0 ± 3 minutes (neck imaging). Conclusion. Utilization of a novel real-time intraoperative LFOVGC imaging approach can provide confirmation of MIBI-avid parathyroid adenoma removal appreciably faster than IOPTH and/or path and may provide a valuable adjunct to parathyroid surgery.

Robotic Mediastinal Parathyroidectomy in a Patient with Maxillary Giant Cell Tumor

A 50-year-old woman with a maxillary giant cell tumor had primary hyperparathyroidism from a mediastinal parathyroid adenoma. Computed tomography showed a mildly enhanced, oval soft tissue nodule (2.5 × 1.5 × 1.7 cm) at the anterosuperior mediastinum. Mediastinal parathyroidectomy was performed with a 3-arm surgical robot. After surgery, the plasma parathyroid hormone level decreased markedly (before surgery, 70.5 pg/ml; after surgery, 5.5 pg/ml; normal reference range, 1.6 to 6.9 pg/ml). The 3-dimensional visualization, high-dexterity, and full range of motion of the robotic system provided an efficient and safe surgical procedure for the mediastinal tumor. The purpose of this case study is to show the feasibility and effectiveness of robot assisted dissection for mediastinal parathyroid gland and to demonstrate the giant cell tumor of the bone can regress after resection of parathyroid adenoma.

Radioactive iodine‐associated changes in thyroid on fine‐needle aspiration

A 64-year-old man with adenocarcinoma of the prostate status postprostatectomy was seen for routine screening. His medical history was significant for deep vein thrombosis, persistent hyperparathyroidism after parathyroid adenoma resection, and hyperthyroidism treated with radioactive iodine ablation 4 years before this visit. Ultrasound-guided fine-needle aspiration with a 20-gauge needle was performed on bilateral thyroid nodules at this follow-up visit. Cytologic examination of the resulting smears revealed a moderately cellular aspirate with cohesive, crowded sheets of atypical follicular epithelial cells on a background of inspissated colloid. Even on low-power examination, scattered atypical giant cells were evident (Fig. C1). Closer examination showed bizarre mononuclear giant cells with dense, oxyphilic cytoplasm (Fig. C-2). The nucleus was round to oval or elongated with a smooth nuclear membrane. The chromatin was slightly hyperchromatic with heterogeneous distribution and clearing with rare intranuclear inclusions. Nucleoli and nuclear grooves were not observed. A diagnosis of atypical follicular epithelial cells consistent with changes owing to therapy was rendered. Antithyroid drugs, radioactive iodine, and surgery are the mainstays of treatment for Graves’ disease. The cytomorphological features have been well described in the literature. 1–3 However, the cytologic characteristics vary

Carcinoids of the stomach and the duodenum with atrophic gastritis in a patient with

Background: A 27-year-old Caucasian male presented in 1977 with heartburn, indigestion and intermittent diarrhea. Treatment with cimetidine, ranitidine, and famotidine resulted in partial improvement, however, his symptoms persisted. Five years later, the patient underwent a parathyroid adenoma resection after hypercalcemia secondary to hyperparathyroidism.In 1986, multiple ulcers were found during an osophagogastroduodenoscopy (EGD), performed due to persistent epigastric discomfort. Two years later, he was diagnosed with Zollinger–Ellison syndrome (ZES) and MEN I Syndrome , however, despite treatment with famotidine, his symptoms persisted. In 1991, antisecretory treatment with the proton pump inhibitor, omeprazole, reduced the patient\'s basal acid output from 3–4 mEq/hr to 0.02–0.08 mEq/hr. In 1994, an EGD revealed multiple duodenal submucosal nodules. In 1997, treatment was switched to lansoprazole. The following year, a mucosal biopsy revealed atrophic gastric mucosa and multiple friable polyps with overlying ulcerations.Multifocal tumors were observed in the setting of endocrine cell hyperplasia and atrophic gastritis. Investigations:CT scan,MRI, somatostatin receptor scintigraphy, EGD, endoscopic ultrasonography and gastric analysis. Diagnosis: Carcinoids of the stomach and duodenum with atrophic gastritis and ZES accompanied by MEN I syndrome. Management:Histamine 2-receptor antagonists (cimetidine, ranitidine and famotidine) followed by proton pump inhibitor therapy (omeprazole, lansoprazole, and intravenous and oral pantoprazole). South African Gastroenterology Journal Vol. 6 (2) 2008: pp. 9-12

The Parathyroids and the Kidney: Fuller Albright Revisited

In 1948, Albright and Reifenstein stated that ‘‘almost all patients with hyperparathyroidism have a marked oliguria immediately following the successful removal of a parathyroid adenoma. In some instances it may be sufficient to cause alarm’’ [1]. This scenario appears to have changed. Today, the risk of hypocalcemia is a great concern after a parathyroid adenoma resection. Some patients are discharged on the day of the operation or on a next-day basis. We have observed, however, that the phenomenon that caused the postoperative course described by Albright and Reifenstein is still occurring, although it is silent in most patients. Notwithstanding, it may cause clinical acute kidney injury, as observed by Laroche et al. [2]. After parathyroidectomy for hyperparathyroidism after renal transplantation, Schwarz et al. correlated the transitory decrease in renal function with a decrease of parathormone (PTH) levels [3]. As PTH reduction is also observed after surgery for primary hyperparathyroidism, we retrospectively analyzed creatinine levels before and during the first 72 h after the operation, when available. A transient increase in creatinine levels above 10% was noted in 77 of 105 cases, and was higher than 50% in 18 cases (17.1%), including one patient that required dialysis [4]. We think that the issue may therefore be of clinical interest. In 38 patients with a preoperative creatinine level less than 1.4 mg/dl (ages varied from 20 to 81 years), it was possible to compare preoperative creatinine levels with the highest levels observed in the first 48 h after the operation. They were significantly increased. The preoperative mean ± standard deviation was 0.84 ± 0.19 mg/dl and, after 48 h, it was 1.13 ± 0.38 mg/dl (p \ 0.0001, Student’s paired test). Astonishingly, in nine patients (23%), the relative increase of creatinine was higher than 50%. Figure 1 illustrates the patterns of creatinine changes observed in these patients. Fortunately, the creatinine levels declined in most patients during the long-term follow-up (they were only slightly elevated when compared to the preoperative levels). Of interest, these observations are in accordance with the effects described by Edvall in 1958 [5]. Perhaps Albright and Reifenstein’s phrase is still valid, but with a small change: ‘‘almost all patients with hyperparathyroidism have a marked creatinine increase immediately following the successful removal of a parathyroid adenoma. In some instances it may be sufficient to cause alarm.’’ Notably, the underlying mechanism of this increase is yet to be explained. We think that until this condition is better understood, nephrotoxic agents or other potential risk factors for kidney injury should be avoided in patients undergoing parathyroidectomy. One may think that the effect here described would be an argument against performing parathyroidectomy in asymptomatic patients. We strongly disagree: parathyroidectomy should be considered very early after the diagnosis, even in asymptomatic cases, before any renal damage caused by hyperparathyroidism ensues. F. Montenegro (&) Department of Head and Neck Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil e-mail: fabiomonte@uol.com.br

Endoscopic Parathyroidectomy: Why and When?

In recent years, several new minimally invasive techniques for parathyroidectomy (MIP) have been developed. There was a rapid worldwide acceptance of mini-open procedures by most surgeons. However, the use of an endoscope remains debatable. This study was designed to determine the role of preoperative imaging studies in the decision-making for using an endoscope during MIP. All patients with sporadic primary hyperparathyroidism (PHPT) and candidate for MIP underwent localizing studies. MIP was proposed only for patients in whom a single adenoma was localized by both ultrasonography and sestamibi scanning. Three locations were described: (1) posterior to the two superior thirds of the thyroid lobe; (2) at the level of or below the inferior pole of the thyroid lobe but in a plane posterior to it; (3) at the level of or below the tip of the inferior pole of the thyroid lobe but in a superficial plane. In locations 1 and 2, the nerve was considered to be at risk and an endoscopic lateral approach was indicated. In location 3, a mini-open approach was indicated. Of the 165 patients operated on for PHPT in 2006, 86 underwent MIP. According to the results of imaging studies, 39 patients presented an adenoma in location 1, 21 in location 2, and 26 in location 3. In locations 1 and 2, 59 patients (1 false-positive) had an adenoma that was located posteriorly, in close proximity to the nerve; all were cured. In location 3, 25 patients (1 false-positive) presented an inferior parathyroid adenoma superficially located; all were cured. There was no transient or permanent laryngeal nerve palsy. In patients who are candidates for MIP, we recommend the use of the endoscope for the resection of parathyroid adenomas that are located deeply in the neck.

Radioguided Thoracoscopic Mediastinal Parathyroidectomy With Intraoperative Parathyroid Hormone Testing

Primary hyperparathyroidism is the leading cause of hypercalcemia in the United States. The goal of this study was to evaluate the feasibility of radioguided thoracoscopic mediastinal parathyroidectomy and intraoperative immunoreactive parathyroid hormone (iPTH) level testing to guide completeness of resection. Mediastinal parathyroidectomy was performed thoracoscopically with intraoperative radioguidance using a hand-held gamma probe after injection of 10 mci of TC-99m sestamibi. Parathyroid excision was confirmed by ex vivo measurement of specimen radioactivity greater than 20% of background. Complete resection was confirmed by a greater than 50% decrease in serum iPTH level at 5 minutes postresection. Four patients had mediastinal parathyroid glands successfully localized and resected thoracoscopically. Mean weight of the excised parathyroid adenoma was 1,714 mg (range, 425 to 4,400 mg). Baseline iPTH levels decreased from a mean of 202 to 39 pg/dL 5 minutes postresection. One patient underwent radioguided resection of a second enlarged cervical parathyroid adenoma at the same setting when his intraoperative iPTH levels failed to fall below 50% of baseline, despite resection of a 440 mg mediastinal parathyroid gland. Median hospital stay was one day. All mediastinal parathyroid glands resected were confirmed adenomas on final histologic examination. All patients were normocalcemic at follow-up (mean, 25 months), indicating cure. Thoracoscopic mediastinal parathyroidectomy with intraoperative iPTH level monitoring is safe and effective. Radioguidance facilitates parathyroid localization. Ex vivo specimen radioactivity of greater than 20% of background confirms parathyroid resection and obviates the need for costly, time-consuming frozen section analysis. A 50% decrease in baseline iPTH level 5 minutes postresection confirms complete resection of parathyroid adenomas.