Single Parathyroid Research Articles

Clinical Features, Treatment, and Surveillance of Hyperparathyroidism-Jaw Tumor Syndrome: An Up-to-Date and Review of the Literature.

Hyperparathyroidism-jaw tumor (HPT-JT) syndrome is an autosomal dominant disorder characterized by parathyroid tumors in association with fibro-osseous jaw tumors and uterine and renal lesions. HPT-JT syndrome is caused by germline mutations of the cell division cycle 73 (CDC73) gene that encodes the parafibromin, a 531-amino acid protein with antiproliferative activity. Primary hyperparathyroidism is the main finding of HPT-JT syndrome, usually caused by a single-gland parathyroid involvement (80% of cases), at variance with other variants of hereditary hyperparathyroidism, in which a multiglandular involvement is more frequent. Moreover, parathyroid carcinoma may occur in approximately 20% of cases. Surgery is the treatment of choice for primary hyperparathyroidism, but the extent of surgery remains controversial, varying between bilateral neck and focused exploration, with subtotal or limited parathyroidectomy. Recently, more limited approaches and parathyroid excisions have been suggested in order to decrease the risk of permanent hypoparathyroidism, the main surgical morbidity following more extensive surgical approaches. Ossifying fibromas of the mandible or maxilla may present only in a minority of cases and, even if benign, they should be surgically treated to avoid tumor growth and subsequent functional limitations. Benign and malignant uterine involvement (including leiomyomas, endometrial hyperplasia, adenomyosis, multiple adenomyomatous polyps, and adenosarcomas) is the second most common clinical feature of the syndrome, affecting more than 50% of CDC73-carrier women. Genetic testing should be performed in all family members of affected individuals, in young patients undergoing surgery for primary hyperparathyroidism, or in presence of other associated tumors, allowing early diagnosis and prompt treatment with more tailored surgery. Moreover, CDC73 mutation carriers should be also periodically screened for primary hyperparathyroidism and the other associated tumors. The present review was aimed to summarize the main clinical features of HPT-JT syndrome, focusing on genetic screening and surgical treatment, and to revise the available literature.

Primary Hyperparathyroidism in a Predominantly Vitamin D Deficient Population: A Single Center Experience

Primary hyperparathyroidism (PHPT) has a variable clinical presentation. Symptomatic PHPT continues to be the predominant form of the disease in the Indian subcontinent, but a decreasing trend of symptomatic cases is observed, and increasing numbers of asymptomatic cases are now being diagnosed. In these cases, 25-hydroxy vitamin D [25(OH)D] shows no correlation with the serum levels of calcium and intact parathyroid hormone (iPTH). To study the characteristics of patients with hyperparathyroidism and the relationship of 25(OH)D with the levels of calcium and i PTH. A study was conducted with 78 consecutive patients diagnosed from 1996 to 2018 with PHPT, in whom the vitamin D status was investigated preoperatively. Of the 78 study subjects, 67 (85.7%) were females and 11 (14.2%) were males. Their age ranged from 16 to 70 years. Nephrolithiasis was the single most common presentation (44.3%) followed by bone pain (42.6%). Only 5% of the subjects were asymptomatic, with a decreasing trend of symptomatic cases and increasing number of asymptomatic cases with time. Their mean serum calcium level was 11.5±1.0 mg/dl, mean serum iPTH level 377±386.1 pg/ml, mean 25(OH)D level 37.2±58.1 ng/ml, while 48% of the patients were vitamin D deficient. The serum levels of 25(OH)D showed no correlation with serum calcium and iPTH levels, whereas it showed a negative correlation with tumor size. Neck ultrasound (US) was indicative of parathyroid pathology and laterality in 89.8% and showed the exact site of the parathyroid pathology in 63.3%. Technetium99sestamibi (MIBI) scan was indicative of parathyroid pathology (side accuracy) in 92.5% and showed the exact site in 85.7% of patients. A single parathyroid gland was involved in 90% of study subjects, double glands in 8% and multiple glands/hyper-plasia in 1.6%. Histopathological examination showed parathyroid adenoma in 86.3% and parathyroid hyperplasia in 7.8%. Temporary post-operative hypocalcemia was detected in 36% of the patients; the cure rate was 98.4%, without any operative mortality. Primary hyperparathyroidism continues to be mainly a symptomatic disease in the Kashmir Valley. There is a decreasing trend of symptomatic cases and an increasing number of asymptomatic cases with time. The level of 25(OH)D has no correlation with serum calcium, iPTH or tumor size in these patients.

Molecular genetic insights into sporadic primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterized by dysregulation of parathyroid hormone release. The large majority of PHPT cases are attributable to sporadic, single-gland parathyroid adenoma, in which MEN1 and CCND1/cyclin D1 are the most well-established drivers of tumorigenesis. Sporadic parathyroid carcinoma, which appears to mostly arise through molecular pathways distinct from those causing benign parathyroid tumors, is rare and is most frequently driven by mutational inactivation of the CDC73 (HRPT2) tumor suppressor gene. Targeted investigation of suspected tumor driver genes, as well as unbiased whole-genome or exome sequencing of small cohorts, have revealed additional novel candidate tumor genes in sporadic parathyroid neoplasia, generally at modest or low mutational frequencies consistent with marked molecular genetic heterogeneity from tumor to tumor. The ability of these additional candidates to participate in the pathogenic process of driving parathyroid tumorigenesis in vivo largely remains to be demonstrated experimentally. This review will summarize the molecular genetic abnormalities identified to date in sporadic PHPT and discuss the strength of evidence for their proposed roles in parathyroid tumor formation.

Predictors of multiglandular disease in primary hyperparathyroidism

BackgroundPrimary hyperparathyroidism (pHPT) is caused by single- or multiglandular disease (MGD). Patients with MGD have an increased risk of complications at surgery and for persistence and recurrence after surgery. The study evaluated whether preoperative clinical and biochemical characteristics could predict MGD in patients with pHPT.MethodsWe retrospectively evaluated patients operated 1989–2013 for first-time, non-hereditary pHPT. MGD was defined in patients with more than one pathological gland excised at surgery or with persistent hypercalcemia after the excision of a single pathological parathyroid gland, confirmed by histopathology. Clinical and biochemical variables were compared in patients with single- and multiglandular disease. Logistic regression was used to identify variables predicting MGD, yielding odds ratios (OR) with 95% confidence intervals (CI).ResultsThere were 707 patients, of which 79 (11%) had MGD. Patients with MGD were more likely to have negative sestamibi scintigraphy than patients with single-gland disease, 15 of 49 (31%) vs. 70 of 402 (17%; p = 0.03), to suffer from diabetes (12 of 74, 16%) vs. 45 out of 626 patients (7.2%; p < 0.01) and had lower preoperative levels of urinary calcium (3.80 vs. 4.44 mmol/L; p = 0.04). Multivariable analysis identified negative scintigraphy (OR 2.42; 95% CI 1.18 to 4.79), diabetes (OR 2.75; 95% CI 1.31 to 4.97) and elevated levels of osteocalcin (OR 3.79, 95% CI: 1.75 to 8.21) as predictors of MGD.ConclusionNegative sestamibi scintigraphy, diabetes and elevated osteocalcin levels were predictors of MGD.

Correlations between parathyroid hormone level, adenoma size, and serum calcium level in patients with primary hyperparathyroidism

Aim: The main goal of this study is to determine the association of preoperative parathyroid hormone (PTH) levels with parathyroid gland adenoma sizes and serum calcium levels in patients with primary hyperparathyroidism caused by single-gland adenoma. Methods: We included all patients with single parathyroid gland adenoma who were admitted to and underwent parathyroidectomy at Security Forces Hospital in Riyadh during a period of 10 years from January 1, 2000 to October 30, 2011. PTH level and serum corrected calcium were recorded 1 day before surgery. Adenoma size was recorded from pathology reports for all patients. Results: In 35 cases of parathyroid adenoma including 12 males (34.3%) and 23 females (65.7%) with an average age of 48.94 years (±13.52), the average PTH level 1 day preoperatively was 769.94 pg/mL (±793.27), the average largest dimension (LD) of parathyroid adenoma was 2.18 cm (±1.38), and the average calcium level 1 day preoperatively was 2.71 mmol/L (±0.3). The mean PTH level in males was 1098.5 pg/mL compared to 598.5 pg/mL in females (P = 0.068), mean LD of parathyroid adenoma in males was 2.34 cm versus 2.09 cm in females (P = 0.72), and mean calcium level in males was 2.70 mmol/L compared to 2.72 mmol/L in females (P = 0.46). A positive correlation was found between PTH level and adenoma size, with a correlation coefficient of 0.29 (P = 0.095). The correlation between PTH level and calcium level was negative, with a correlation coefficient of −0.033 (P = 0.85). Negative correlation was also found between adenoma size and calcium level, with a correlation coefficient of −0.033 (P = 0.85). Conclusion: Based on the findings of this study, preoperative PTH level or serum calcium level cannot be used to predict adenoma size. Further prospective studies with larger sample sizes are recommended.

Parathyroid, Thyroid and Recurrent Laryngeal Nerve Anatomy in an Indian Rhinoceros (Rhinoceros unicornis)

IntroductionThe parathyroid gland was first identified in the Indian rhinoceros in 1849 by Sir Richard Owen. We performed a necropsy in an Indian rhinoceros, recapitulating Owen’s dissection and display what appear to be the initial identification of the recurrent laryngeal nerve in situ and the anatomy and histology of the largest rhinoceros parathyroid glands yet identified.Materials and methodsPatrick T. Rhino, a 41-year-old Indian rhinoceros was born in 1974. His early years were unremarkable. In 2006, he was donated to White Oak Conservation in Yulee, Florida, where he bred and sustained minor injuries. In his geriatric years, he developed a cataract and degenerative joint disease (DJD). At age 41, he developed progressive ataxia and lameness and was euthanized to minimize suffering when he was unable to stand. ROS, FH, SH and medication history were unremarkable. Physical exam was age and species appropriate. Pre-mortem serum demonstrated: creat 1.8 mg/dL (0.8–2.1), calcium 10.6 mg/dL (9.7–13.1), phos 3.8 mg/dL (2.5–6.7), alk phos 69 U/L (26–158) and intact PTH 44.1 pg/mL (rhinoceros reference range: unknown). Necropsy revealed intervertebral DJD with thoracic spondylosis, which combined with osteoporosis, resulted in thoracic myelopathy and ataxia. The neck block was sent in formalin to the Yale University School of Medicine.ResultsDetailed dissection was performed under loupe magnification. Presumed structures were photographed in situ and biopsied. The thyroid was identified deep to the strap muscles, received its blood supply from the inferior and superior thyroid arteries and was blue in color. The right recurrent laryngeal nerve, identified and photographed in situ for the first time in the rhinoceros, was deep to the inferior thyroid artery and was traced throughout its cervical course. Single parathyroid glands identified on the lateral thyroid lobes received their blood supply from the inferior thyroid arteries and were confirmed histologically. They appear to be the largest parathyroids yet identified in the rhinoceros with estimated weights of 6,280 and 11,000 mg, respectively. Although the etiology of the parathyroid gland enlargement is unknown, the specimen has been preserved recapitulating the dissection performed by Sir Richard Owen.ConclusionThe parathyroids, thyroid and recurrent laryngeal nerve were identified in an Indian rhinoceros. This appears to be the first display of the rhinoceros recurrent laryngeal nerve in situ, and the parathyroid glands are the largest yet identified in the rhinoceros.

Risk-factors for nodular hyperplasia of parathyroid glands in sHPT patients.

IntroductionNodular hyperplasia of parathyroid glands (PG) is the most probable cause of medical treatment failure in secondary hyperparathyroidism (sHPT). This prospective cohort study is located at the interface of medical and surgical consideration of sHPT treatment options and identifies risk-factors for nodular hyperplasia of PG.Material and methodsOne-hundred-eight resected PG of 27 patients with a broad spectrum of sHPT severity were classified according to the degree of hyperplasia by histopathology. Twenty routinely gathered parameters from medical history, ultrasound findings of PG and laboratory results were analyzed for their influence on nodular hyperplasia of PG by risk-adjusted multivariable binary regression. A prognostic model for non-invasive assessment of PG was developed and used to weight the individual impact of identified risk-factors on the probability of nodular hyperplasia of single PG.ResultsIndependent risk-factors for nodular hyperplasia of single PG were duration of dialysis in years, PG volume in mm3 determined by ultrasound and serum level of parathyroid hormone in pg/mL. Multivariable analyses computed a model with an Area Under the Receiver Operative Curve of 0.857 (95%-CI:0.773–0.941) when predicting nodular hyperplasia of PG. Theoretical assessment of risk-factor interaction revealed that the duration of dialysis had the strongest influence on the probability of nodular hyperplasia of single PG.ConclusionsThe three identified risk-factors (duration of dialysis, PG volume determined by ultrasound and serum level of parathyroid hormone) can be easily gathered in daily routine and could be used to non-invasively assess the probability of nodular hyperplasia of PG. This assessment would benefit from periodically collected data sets of PG changes during the course of sHPT, so that the choice of medical or surgical sHPT treatment could be adjusted more to the naturally changing type of histological PG lesion on an individually adopted basis in the future.

The Preservation and Autotransplantation of the Parathyroid Glands in Total Thyroidectomy in Patients With Thyroid Cancer—A Strategy for Avoiding Permanent Hypoparathyroidism

Hypoparathyroidism is a complication that occurs after total thyroidectomy (TT) in patients with thyroid cancer. We tried to determine a strategy for avoiding permanent hypoparathyroidism. A total of 42 patients underwent TT for thyroid cancer between April 2009 and March 2014. One or more parathyroid glands (PGs) could be macroscopically preserved in all of the patients. First, we evaluated the association between the number of PGs that were macroscopically preserved and the postoperative course in 28 patients without autotransplantation. The number of preserved PGs was not associated with postoperative tetany or the serum levels of calcium or phosphorous on postoperative day 1, or the proportion of patients who needed to take calcium supplements or a vitamin D analog. However, only the patients with a single preserved PG required calcium supplementation for longer than 1 year (33.3%, P &amp;lt; 0.05). Next, we compared the clinical course with PG autotransplantation in 16 patients in whom a single PG was preserved. Although the result was not statistically significant, only the patients without autotransplantation required calcium supplementation for longer than 1 year. To avoid permanent hypoparathyroidism after TT, it should be essential to preserve at least 2 PGs or to preserve 1 PG and perform autotransplantation.

Location of abnormal parathyroid glands: lessons from 810 parathyroidectomies

BackgroundPrimary hyperparathyroidism (pHPT) is commonly treated with targeted parathyroidectomy (PTX) guided by preoperative imaging and intraoperative parathormone monitoring. Despite advanced imaging techniques, failure of parathyroid localization still occurs. This study determines the anatomical distribution of single abnormal parathyroid glands, which may help direct the surgeon in PTX when preoperative localization is unsuccessful. MethodsA retrospective review of prospectively collected data of 810 patients with pHPT who underwent initial PTX at a tertiary medical center was performed. All patients had biochemically confirmed pHPT and single-gland disease. Abnormal parathyroid gland localization was determined at time of operation, correlated with operative and pathology reports, and confirmed by operative success defined as eucalcemia for ≥6 mo after PTX. Patients with multiple endocrine neoplasia, secondary, tertiary, or familial hyperparathyroidism, multiglandular disease, parathyroid cancer, and ectopic glands were excluded. Data were analyzed by chi-square and Z-test analyses. ResultsAmong 810 patients who underwent PTX for pHPT, single abnormal parathyroid glands were unequally distributed among the four eutopic locations (left superior, 15.7%; left inferior, 31.3%; right superior, 15.8%; right inferior, 37.2%; P < 0.01). Abnormal inferior parathyroid glands (68.5%) were significantly more common than abnormal superior glands (31.5%), respectively (P < 0.01). In men, the most common location for single abnormal parathyroid glands was the right inferior position (43.4%, P < 0.01). Overall, there was no significant difference in laterality. ConclusionsThis large series of patients suggests that single eutopic abnormal parathyroid glands are more likely to be inferior. In men, moreover, if an abnormal parathyroid gland is not localized preoperatively, the right inferior location should be explored first. Nevertheless, successful PTX remains predicated on knowledge of parathyroid anatomy, experience, and judgment of the surgeon.

Unilateral Clearance for Primary Hyperparathyroidism in Selected Patients with Multiple Endocrine Neoplasia Type 1

BackgroundPrimary hyperparathyroidism is the most common manifestation of multiple endocrine neoplasia type 1 (MEN1). Guidelines advocate subtotal parathyroidectomy (STP) or total parathyroidectomy with autotransplantation due to high prevalence of multiglandular disease; however, both are associated with a significant risk of permanent hypoparathyroidism. More accurate imaging and use of intraoperative PTH levels may allow a less extensive initial parathyroidectomy (unilateral clearance, removing both parathyroids with cervical thymectomy) in selected MEN1 patients with primary hyperparathyroidism.MethodsWe performed a retrospective cohort study at a high-volume tertiary medical center including patients with MEN1 and primary hyperparathyroidism, who underwent STP or unilateral clearance as their initial surgery from 1995 to 2015. Unilateral clearance was offered to patients who had concordant sestamibi and ultrasound showing a single enlarged parathyroid gland. For both the groups, we compared rates of persistent/recurrent disease and permanent hypoparathyroidism.ResultsEight patients had unilateral clearance and 16 had STP. Subtotal parathyroidectomy patients were younger (37 vs 52 years). One patient in each group had persistent disease. One (13 %) unilateral clearance and five (31 %) STP patients had recurrent hyperparathyroidism after a mean follow-up of 47 and 68 months (p = 0.62). No unilateral clearance patients and two of 16 SPT patients had permanent hypoparathyroidism (p = 0.54).ConclusionsSome MEN1 patients with primary hyperparathyroidism who have concordant localizing studies may be selected for unilateral clearance as an alternative to STP. For appropriately selected MEN1 patients, unilateral clearance can achieve similar results as STP and has no risk of permanent hypoparathyroidism, and may facilitate possible future reoperations.

Results of intraoperative gamma probe survey and frozen section in surgical treatment of parathyroid adenoma in children

AimTo evaluate the use of intraoperative gamma probe survey (IGPS) and frozen section (FS) in the surgical treatment of parathyroid adenoma (PA) in children. Patients and methodsChildren operated for PA between 2000 and 2015 were evaluated for age, sex, clinical features, presenting symptoms, diagnostic methods and results of surgical treatment retrospectively. ResultsSeven patients operated for PA were included in the study. The mean age of the patients was 14.58years (11–17years) and male to female ratio was 4:3. Presenting symptoms were non-specific such as fatigue, weakness and abdominal pain (n=4). Six patients (85.8%) had adenoma of single parathyroid gland whereas remaining patient has involvement of two glands (14.2%). Localizations of adenomas were left inferior (n=3, 42.8%), right inferior (n=2, 28.3%), right superior (n=1, 14.2%), left superior (n=1, 14.2%) and intrathymic (n=1, 14.2%). In case with involvement of more than one gland, adenomas were localized at right superior/left inferior glands. The mean longest diameter of the adenomas were 14.8mm (4–23mm) and all of the cases were underwent USG and Tc-99m sestamibi scan. During surgical excision, FS were used in 5 cases, and 4 cases had IGPS after preoperative radioactive substance injection. In one patient, injection was performed directly into the adenoma and 3 patients had systemic injection. Patient who had injection directly into the involved gland had positive gamma counts in the adjacent tissues because of local spread of radioactive substance and diagnosis was also confirmed with FS. In two of the cases, adenoma excision was performed without FS with only IGPS. None of the patients had preoperative and postoperative complications. ConclusionPA is rare in children and appropriate gland excision can be obtained also by the help of IGPS after injection of radioactive substance, and frozen section examination as well as intraoperative parathormone (PTH) screening. IGPS is a helpful tool to define the target tissue during surgery in order to avoid extensive dissection. Since direct injection of involved gland may cause accumulation of radioactivity in the adjacent tissues, surgeons must be aware of advantages and disadvantages of different radiolabeling techniques.

Parathyromatose : une cause rare d’hyperparathyroïdie récidivante

IntroductionParathyromatosis is a rare cause of recurrent hyperparathyroidism. It results from hyperfunctioning parathyroid tissue scattered throughout the thyroid bed region. Case reportA 51-year-old man with a history of parathyroidectomy, presented 18 years later with recurrent primary hyperparathyroidism. Surgical exploration identified a single parathyroid gland. The act was completed by a central compartment dissection and ipsilateral lobectomy. The patient was free of recurrence after a one-year follow-up. ConclusionParathyromatosis a rare cause of recurrent hyperparathyroidism. Its management is challenging. Extensive surgery is required with clearance of the central neck compartment and homolateral lobectomy. Medical therapy could be used to decrease parathormone level in recurrent parathyromatosis.

Reoperative Parathyroidectomy: Overly Descended Superior Adenoma.

To identify the importance of the ectopic, overly descended superior parathyroid adenoma variant and its prevalence in primary and reoperative parathyroid surgery and the implications for successful initial parathyroidectomy. Case series with planned data collection. Tertiary endocrine surgery practice in an academic medical center. An analysis was undertaken of 561 consecutive patients undergoing parathyroid surgery in a tertiary endocrine surgery practice from March 2004 to April 2013. There were 270 patients who had curative primary or reoperative surgery for single-gland parathyroid adenomas during this time. Clinical records, imaging studies, operative reports, and pathology findings were evaluated, and cases from a subset of patients who had an ectopic, overly descended superior parathyroid adenoma were further analyzed. The prevalence of this entity in primary and revision surgeries was calculated. Among the 270 patients with single-gland parathyroid adenomas, there were 251 primary operations and 19 reoperative procedures referred from outside institutions. An ectopic, overly descended superior parathyroid adenoma was present in 23 (9.2%) primary cases and 4 (21.1%) reoperative cases. An overly descended superior parathyroid adenoma is frequently encountered during primary parathyroid surgery. It is more than twice as common in reoperative parathyroidectomy, reflecting the propensity to be missed at the first exploration. Recognition and proper treatment of this entity at the initial operation will reduce the need for revision surgery.

Limited Parathyroidectomy in Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism: A Setup for Failure.

Recently, some surgeons have suggested that minimally invasive parathyroidectomy guided by preoperative localizing studies of patients with multiple endocrine neoplasia type 1 (MEN1)-associated primary hyperparathyroidism (pHPT) provides an acceptable outcome while minimizing the risk of hypoparathyroidism. This study aimed to evaluate the outcome for MEN1 patients who underwent limited parathyroidectomy compared with subtotal parathyroidectomy. The authors performed a retrospective analysis of 99 patients with MEN1-associated pHPT who underwent at least one parathyroid operation at their institution. Preoperative imaging studies, intraoperative findings, and clinical outcomes for patients were compared. A total of 99 patients underwent 146 operations. Persistent pHPT was significantly higher in patients whose initial operations involved removal of 1 or 2 glands (69 %) or 2.5 to 3 glands (20 %) compared with those who had 3.5 or more glands removed (6 %) (P < 0.01). Persistent pHPT occurred in 5 % of all operations that cumulatively removed 3.5 or more parathyroid glands compared with 40 % of operations that removed 3 or fewer glands (P < 0.01). The single largest parathyroid gland was correctly identified preoperatively in 69 % (22/32) of the patients. However, preoperative localizing studies missed enlarged contralateral parathyroid glands in 86 % (19/22) of these patients. Preoperative localizing studies missed the largest contralateral parathyroid gland in 16 % (5/32) of the patients. Limited parathyroidectomy in MEN1 is associated with a high failure rate and should not be performed. Preoperative identification of a single enlarged parathyroid gland in MEN1 is not reliable enough to justify unilateral neck exploration because additional enlarged contralateral parathyroid glands are frequently missed.

Parathyroid adenomas – a cluster of boys

Primary hyperparathyroidism is rare in children and adolescents, representing 1% of all cases, with a slight female preponderance [1-3]. 3-5% of cases are hereditary and may represent the initial clinical manifestation of multiple endocrine neoplasia type 1 (MEN1). Over the last 30 years, ten cases of primary hyperparathyroidism have presented to our hospital, all aged 11-14 years, with nine cases being male, and eight cases over the last six years. Presenting features included headache and blurred vision in five patients, abdominal pain and nausea (in three), renal calculi (in four), generalized bone pain (in three) and two asymptomatic. One patient had received radiation for acute lymphoblastic leukaemia. Other history included ADHD (in one patient), mild developmental delay (in one), depression (in one) and fine motor difficulties (in one). No patients had a significant family history. Peak corrected calcium level ranged between 3.12-3.65 mmol/L (2.1-2.65), peak PTH level 6.9-154 pmol/L (1-7), and urine calcium creatinine ratio 0.47-2.76mM/mM (0.04-0.7). Serum alkaline phosphatase was 212-549U/L (80-355), and normal in three of the renal calculi patients. Bony changes were seen in three patients, with flaring of clavicles and widening of epiphyses, decreased phalangeal cortical density and osteopenia. 25-OH calciferol was low at 27-39nmol/L (>50) in 3 of 7 patients in whom it was measured. Thyroid ultrasound detected suspicious lesions in seven patients and was normal in three patients. Sestamibi scan was negative for three patients (with one ectopic gland) and indicated a single overactive gland in seven patients. All patients had a positive result from at least one modality. All patients underwent surgical resection, with a single benign parathyroid adenoma identified in each case. The only significant post-operative issues were initial hypocalcaemia (lowest cCa 1.8mmol/L) in eight patients, requiring management with calcitriol and elemental calcium. There was normalisation of calcium over several weeks post-operatively, with gradual weaning of supplementation required. In all, post-operative PTH level was suppressed. MEN1 screening has been negative for all patients. This case series illustrates the difficulties involved in the diagnosis of parathyroid adenoma in children, requiring both scintigraphy and ultrasound. Scintigraphy has been reported in the literature to have 88% sensitivity, lower in our case series, compared to 78% sensitivity for ultrasound [4]. The gender mix of our cases differs significantly from other reported case series, being predominantly male [3,5] and there is a suggestion of increasing incidence over recent years.

Minimally invasive parathyroidectomy without using intraoperative parathyroid hormone monitoring or gamma probe.

Minimal invasive parathyroidectomy (MIP) is a common surgical technique for the treatment of primary hyperparathyroidism (PHPT) and is usually done in conjunction with positive imaging techniques. We aimed to assess the results of this technique, performed without the use of intraoperative tests, in cases with PHPT caused by a single parathyroid adenoma. The data for patients who were diagnosed with PHPT were assessed retrospectively. Only those who had undergone a parathyroid adenoma localization study with ultrasonography (US) and parathyroid scintigraphy (PS) before the surgery, along with those patients for whom the MIP technique was routinely performed with frozen pathology, were included. The study group was made up of 65 patients who had undergone the MIP technique. The mean age of the patients was 56±14 (20-81), with most being females [M/F: 19 (29.2%)/46 (70.8%)]. The mean calcium values before the operation were 11.24±1.26 mg/dL (8-15.5) (normal range: 8.4-10.2), and the parathyroid hormone (PTH) values were 388 pg/mL (249-707.75). These same values, measured 24 hours after the operation, were determined as 9.04±1.04 mg/dL (6.8-13.9) and 27 pg/mL (6-86), respectively. The follow-up period for the patients was an average of 26.6±9.4 (3-76) months, and only 3 (4.6%) cases of persistent hyperparathyroidism were detected within this period. Our success rate with MIP in PHPT cases was determined to be 95.4%; therefore, this technique may be applied with a high success rate without any assistance from intraoperative tests, such as rapid serum PTH (rPTH) assays or gamma probes, in the presence of localization results of PS and US.

Reoperative Parathyroid Surgery: Role of the Overly‐Descended Superior Adenoma in Persistent Disease

Objectives: (1) Recognize that failure to identify an ectopic, overly-descended superior parathyroid adenoma may contribute to failed parathyroid exploration. (2) Understand the prevalence of an ectopic, overly-descended superior parathyroid adenoma in both primary and reoperative parathyroid surgery in patients with single-gland primary hyperparathyroidism. (3) Describe the findings that should lead the clinician to suspect the presence of an ectopic, overly-descended superior adenoma. Methods: A retrospective review of patients undergoing curative surgery for single-gland parathyroid adenomas at a single institution was performed. Clinical records, imaging studies, operative reports, and pathology findings were evaluated, and all instances of an ectopic, overly-descended superior parathyroid adenoma were identified. The prevalence of this entity in both primary and revision surgeries was calculated. Results: There were 270 cases of curative surgery for single-gland parathyroid adenomas during the study period. There were 251 primary operations and 19 re-operative procedures referred from outside institutions. An ectopic, overly-descended superior parathyroid adenoma was present in 9.2% of primary cases and in 21.1% of reoperative cases. While this condition was more common in the reoperative setting (as expected) the incidence in the primary setting was higher than anticipated, and in fact the difference did not reach statistical significance ( P = .1). Conclusions: An overly-descended superior parathyroid adenoma is common in both the reoperative and primary settings. Recognition and proper treatment of this entity at the initial operation will reduce the need for revision surgery.

Successful Detection and Removal of a Functional Parathyroid Adenoma in a Pony Using Technetium Tc 99m Sestamibi Scintigraphy

Successful Detection and Removal of a Functional Parathyroid Adenoma in a Pony Using Technetium Tc 99m Sestamibi Scintigraphy

Surgical Technique: Paratiroidectomia Minim Invazivă - Aspecte Tehnice, Experienţă Iniţială, Scurt Review al Literaturii

Primary hyperparathyroidism (pHPT) is a common disease, in the majority of cases determined by a single solitary parathyroid adenoma; it is more frequently encountered among older women, between 50-60 years. Due to advances in imaging, preoperative localization of the hyperfunctioning or enlarged gland is almost always possible. In this perspective the classic bilateral neck exploration shifted to limited (focused) surgical approaches i.e. minimally invasive parathyroidectomy (MIP). The aim of this study is to do a short literature review of MIP surgical techniques and to present the surgical procedure we have used, along with our initial experience, respectively.

Ultrasound-Guided Percutaneous Laser Ablation in Patients With Primary Hyperparathyroidism

Brief Description of the Purpose of the StudyTo assess the efficacy of ultrasound-guided percutaneous laser ablation (US-PLA) of abnormal parathyroid gland in patients with primary hyperparathyroidism (PHPT).MethodsThirty six patients with PHPH underwent 2-4 sessions of US-PLA for a single abnormal parathyroid gland, probably a parathyroid adenoma (PA), with the diode medical laser of 1030nm wavelength. PA were detected with ultrasound, proven with SPECT and exhibited high PTH (588-4929 pg/ml) in the needle washout after fine needle aspiration biopsy. The size of PA ranged from 3×9×7mm to 6×10×22mm. Follow-up period was 1month - 1 year after US-PLA.Main ResultsPA was not sonographically detected in 6 cases after US-PLA. The rest 30 cases demonstrated 4.5 times decrease in volume (from 0.32 ± 0.12 cm3 to 0.07 ± 0.01cm3) in 1 month after US-PLA. All detected PA were avascular with color and power Doppler imaging. Blood intact parathyroid hormone (iPTH) decreased 3.4 times in general from 183 ± 56 pg/ml to 53 ± 5 pg/ml and blood ionized calcium from 1.30 ± 0.06 mmol/l to 1.11 ± 0.06 mmol/l. The size of PA and iPHT level exhibited staged changes with increase during first days after US-PLA followed by their gradual decrease.Importance of the ConclusionsUS-PLA can be used as an alternative treatment modality in selected patients with PHPT. Brief Description of the Purpose of the StudyTo assess the efficacy of ultrasound-guided percutaneous laser ablation (US-PLA) of abnormal parathyroid gland in patients with primary hyperparathyroidism (PHPT). To assess the efficacy of ultrasound-guided percutaneous laser ablation (US-PLA) of abnormal parathyroid gland in patients with primary hyperparathyroidism (PHPT). MethodsThirty six patients with PHPH underwent 2-4 sessions of US-PLA for a single abnormal parathyroid gland, probably a parathyroid adenoma (PA), with the diode medical laser of 1030nm wavelength. PA were detected with ultrasound, proven with SPECT and exhibited high PTH (588-4929 pg/ml) in the needle washout after fine needle aspiration biopsy. The size of PA ranged from 3×9×7mm to 6×10×22mm. Follow-up period was 1month - 1 year after US-PLA. Thirty six patients with PHPH underwent 2-4 sessions of US-PLA for a single abnormal parathyroid gland, probably a parathyroid adenoma (PA), with the diode medical laser of 1030nm wavelength. PA were detected with ultrasound, proven with SPECT and exhibited high PTH (588-4929 pg/ml) in the needle washout after fine needle aspiration biopsy. The size of PA ranged from 3×9×7mm to 6×10×22mm. Follow-up period was 1month - 1 year after US-PLA. Main ResultsPA was not sonographically detected in 6 cases after US-PLA. The rest 30 cases demonstrated 4.5 times decrease in volume (from 0.32 ± 0.12 cm3 to 0.07 ± 0.01cm3) in 1 month after US-PLA. All detected PA were avascular with color and power Doppler imaging. Blood intact parathyroid hormone (iPTH) decreased 3.4 times in general from 183 ± 56 pg/ml to 53 ± 5 pg/ml and blood ionized calcium from 1.30 ± 0.06 mmol/l to 1.11 ± 0.06 mmol/l. The size of PA and iPHT level exhibited staged changes with increase during first days after US-PLA followed by their gradual decrease. PA was not sonographically detected in 6 cases after US-PLA. The rest 30 cases demonstrated 4.5 times decrease in volume (from 0.32 ± 0.12 cm3 to 0.07 ± 0.01cm3) in 1 month after US-PLA. All detected PA were avascular with color and power Doppler imaging. Blood intact parathyroid hormone (iPTH) decreased 3.4 times in general from 183 ± 56 pg/ml to 53 ± 5 pg/ml and blood ionized calcium from 1.30 ± 0.06 mmol/l to 1.11 ± 0.06 mmol/l. The size of PA and iPHT level exhibited staged changes with increase during first days after US-PLA followed by their gradual decrease. Importance of the ConclusionsUS-PLA can be used as an alternative treatment modality in selected patients with PHPT. US-PLA can be used as an alternative treatment modality in selected patients with PHPT.