Solitary Adenoma Research Articles

Primary and "Pre-Primary" Aldosteronism in Resistant Hypertension: A Practical, Pragmatic, and Prudent Approach in Resource-Limited Milieu.

Introduction Primary aldosteronism (PA), once considered rare, is now recognized as the most common cause of secondary hypertension, accounting for almost a quarter of resistant hypertension (RH) cases. Despite this, PA remains underdiagnosed, with an extremely low percentage of RH patients undergoing screening. Methods In a specialty diabetes-endocrinology clinic, the aldosterone:renin ratio (ARR) was assessed in 115 consecutive RH patients (ages 21-93 years; 47% male; 87% with type 2 diabetes). Fasting blood samples were drawn in a standing position after 30 minutes of walking. Adrenal imaging (CT/MRI) was performed for those with an ARR >20. Results ARR values ranged from 0.4 to 227 (ARR <10 (35%); 11-20 (19%), 21-40 (25%), and >40 (21%)), with corresponding stepwise decreasing plasma renin activity (PRA) (P= 1E-6) and increasing serum aldosterone (SA) (P= 8E-7). Increasing ARR tended to be associated with an increase in serum creatinine (R= 0.23; P= 0.03) and a decrease in estimated glomerular filtration rate (eGFR) (R= -0.24; P= 0.02) and an increase in urine albumin: creatinine ratio. The ARR> 40 group displayed the highest serum creatinine, lowest eGFR, higher urine albumin: creatinine ratio, highest serum sodium, lowest serum potassium, and highest (44%) abnormal adrenal imaging (bilateral hyperplasia diffuse/nodular; solitary adenoma), reflecting a later stage of the pathological spectrum. PA treatment with mineralocorticoid receptor antagonists (MRAs) had a salutary effect. Conclusions Our observations further reinforce that PA is not a binary condition, but exists as a spectrum disorder responsive to MRAs, even in patients with mildly elevated or normal aldosterone levels. Early disease detection/recognition ("renin-independent aldosterone production") can be facilitated by marking "pre-primary" aldosteronism (ARR 11-20), followed by monitoring progression (periodic rescreening) and optimizing treatment, with hopeful mitigation of end-organ damage in RH.

Preoperative visualization of parathyroid pathology in patients with primary hyperparathyroidism using PAT/KT: a retrospective study

INTRODUCTION: Topical diagnosis of pathologically altered parathyroid glands in patients with primary hyperparathyroidism is a challenge both for specialists of radial diagnostics and for planning the scope of surgical intervention. The choice of diagnostic modality for localization of parathyroid glands depends on the availability of the method for a particular medical center. PET/CT is a promising method to determine the localization of parathyroid adenomaOBJECTIVE: To analyze the experience of using PET/CT with 11C-methionine and PET/CT with 11C-choline for preoperative diagnosis of parathyroid pathology in patients with primary hyperparathyroidism.MATERIALS AND METHODS: 72 patients diagnosed with PHPT and underwent surgical treatment were included in the study. Before surgical intervention all patients underwent laboratory and instrumental investigations in the scope of: blood tests for PTH, TTH, ionized calcium, calcitonin, 25(OH)D, creatinine, phosphorus, ultrasound of the neck, computer tomography of the neck with intravenous bolus contrasting.RESULTS: PET/CT showed the highest rates of DA in the patient group before primary surgery — 90.9%, compared with ultrasound (89.6%) and CT with IV contrast (84.9%). In the group of solitary adenomas of ectopic MTCS, PET/CT also had a higher DA — 92.8% than the other modalities. In patients with relapsed or persistent disease, the informativity rates of CT with intravenous contrast and PET/CT were similar (Se — 100%, Sp — 94.1%, DT — 96.2%).DISCUSSION: The algorithm for preoperative evaluation of patients to identify the location of pathologic parathyroid glands now includes imaging with two modalities: Neck ultrasound and radionuclide imaging: planar scintigraphy (washout/subtraction), SPECT, SPECT-CT. If the results are questionable, a CT scan of the neck with contrast or PET/CT is performed as a second step. None of the modalities has 100% diagnostic accuracy. Our study demonstrated the superiority of PET/CT over ultrasound and CT w/in contrast in a group of patients scheduled for primary surgical treatment. In a small group of patients, high informative rates of PET/CT and CT with contrast were demonstrated before reoperation, confirming the great potential of these techniques in these patients.CONCLUSION: PET/CT with 11C-methionine and PET/CT with 11C-choline have high diagnostic accuracy in patients with primary hyperparathyroidism before reoperation. PET/CT and CT with contrast showed similarly high diagnostic accuracy for the diagnosis of parathyroid adenoma with persistence or recurrence of the disease in patients with primary hyperparathyroidism.

12350 A Rare Case Of Giant Parathyroid Adenoma Managed Medically For 8 Months: A Case Report

Abstract Disclosure: S. Labram: None. L. Bilandzic: None. Background: Single parathyroid adenoma is the most common cause of primary hyperparathyroidism, and is attributed to approximately 85% of cases[1]. However, those classified as giant (weighing over 3.5 g and having a size greater than 2cm2) are exceedingly rare. This reports a rare case of primary hyperparathyroidism caused by giant parathyroid adenoma and details biochemical response following medical and surgical management. Case Report: A 64 year old black female presented with severe abdominal pain, confusion and constipation. Investigations revealed severe hypercalcemia of 17.3 mg/dl with massively elevated parathyroid hormone of 1255 pg/mL. Ultrasound showed a large hypoechogenic lobulated mass inferior to the left thyroid lobe representing a giant parathyroid adenoma. Due to delayed surgery the patient was initially treated medically over the course of 8 months. Over these months she was admitted to hospital 3 times for symptomatic hypercalcemia and received a total of 3 zolendronic acid infusions. Despite this she was unable to achieve long term remission of hypercalcemia. Cinacalcet was added and tolerated at the dose of 30 mg daily. Hypercalcemia improved, but remained elevated at a range of 11-13 mg/dL and the symptoms of brain fog and constipation did not subside entirely. She was eventually able to undergo surgical resection, and a giant parathyroid adenoma weighing 8.9 g was excised. Intraoperative intact parathyroid hormone (IOiPTH) sampling showed &amp;gt; 50% reduction (prior to removal 878pg/mL, 10 minutes after removal 132 pg/ml, 20 minutes after removal 96pg/mL). Pathological review showed an atypical parathyroid tumor. As the tumor lacked invasive growth it did not meet criteria for carcinoma. Conclusions: This is a rare case of primary hyperparathyroidism caused by a giant solitary parathyroid adenoma. The gold standard for management of primary hyperparathyroidism secondary to parathyroid adenoma is minimally invasive parathyroidectomy. However in our case, due to inability to access immediate surgery, challenging and prolonged medical treatment of severe hypercalcemia followed for 8 months. Ultimately, normalization of calcium level was achieved only by surgical intervention. IOiPTH measurements showed appropriate decrease confirmatory for the complete removal of the adenoma.

APPROACH TO A PATIENT WITH CLINICALLY AND BIOCHEMICALLY ACTIVE PRIMARY HYPERPARATHYROIDISM DESPITE NEGATIVE SESTAMIBI 99MTC

Introduction: Primary hyperparathyroidism (PHPT) resulting from increased parathyroid hormone (PTH) secretion. In 80% of cases the cause is a solitary adenoma. It occurs more often in women. The gold standard in the diagnosis of PHPT is MIBI 99m Tc scintigraphy. Patient presentation. A 35-year-old women is referred to outpatient clinic due to high values of PTH, calcium and frequent recurring nephrolithiasis. From the laboratory analysis we show: PTH 317 pg/ml, Ionized calcium 1.71 (1.16 to 1.31 mmol/L); phosphates 0.73mmol/L; Vitamine D3 18.68 ng/ml. The patient is referred for neck ultrasound and bone densitometry (DEXA). A hypoechoic nodule with dimensions of 0.69x0.63x0.67 cm is visualized on ultrasound under the right lobe of the thyroid gland. In the DEXA scan, osteopenia is detected (T-score -2.2). Sestamibi scintigraphy was performed in two repetitions where no adenoma of the parathyroid gland was detected. The patient is referred for neck computed tomography (CT); a small nodule suspicious for parathyroid adenoma is visualized. Due to the clinical manifestation and the constant high values of hypercalcemia, the patient is referred for parathyroidectomy. After the operation, a few days later, the values of PTH (63.5 pg/ml) and ionized calcium (1.18 mmol/L) were normal. Conclusion. Sestamibi scintigraphy is rarely negative during clear clinical and biochemical signs. The sensitivity of Sestamibi is 80-100%, and in cases where it is negative, especially when the volume of the nodule in PHPT is small, additional analyzes such as neck CT, 18FCholine PET/CT enable the decision-making of the definitive treatment – parathyroidectomy in PHPT.

Imaging Recommendations for Diagnosis and Management of Primary Parathyroid Pathologies: A Comprehensive Review.

Parathyroid pathologies are suspected based on the biochemical alterations and clinical manifestations, and the predominant roles of imaging in primary hyperparathyroidism are localisation of tumour within parathyroid glands, surgical planning, and to look for any ectopic parathyroid tissue in the setting of recurrent disease. This article provides a comprehensive review of embryology and anatomical variations of parathyroid glands and their clinical relevance, surgical anatomy of parathyroid glands, differentiation between multiglandular parathyroid disease, solitary adenoma, atypical parathyroid tumour, and parathyroid carcinoma. The roles, advantages and limitations of ultrasound, four-dimensional computed tomography (4DCT), radiolabelled technetium-99 (99mTc) sestamibi or dual tracer 99mTc pertechnetate and 99mTc-sestamibi with or without single photon emission computed tomography (SPECT) or SPECT/CT, dynamic enhanced magnetic resonance imaging (4DMRI), and fluoro-choline positron emission tomography (18F-FCH PET) or [11C] Methionine (11C -MET) PET in the management of parathyroid lesions have been extensively discussed in this article. The role of fluorodeoxyglucose PET (FDG-PET) has also been elucidated in this article. Management guidelines for parathyroid carcinoma proposed by the American Society of Clinical Oncology (ASCO) have also been described. An algorithm for management of parathyroid lesions has been provided at the end to serve as a quick reference guide for radiologists, clinicians and surgeons.

Sporadic non-ampullary duodenal adenoma with high grade dysplasia: A rare case report

Duodenal adenomatous polyps are usually classified according to the mucin phenotype into intestinal (89.1%) and gastric type (10.9%). The intestinal-type polyps are morphologically divided into tubular and tubulo-villous adenomas, whereas the gastric-type into pyloric gland adenomas and foveolar adenomas. The duodenal adenomas are also clinically categorised into sporadic duodenal adenomas and adenomas associated with genetic syndromes for instance familial adenomatous polyposis (FAP), or MUTYH associated adenomatous polyposis (MAP). Sporadic duodenal adenomas are less common than FAP related adenomas and are usually recognized in elderly men in their 6 to 8 decade of life. The large non-ampullary solitary duodenal adenomas ≥ 20 mm in diameter with high grade dysplasia show a significantly high risk of progression to adenocarcinoma and therefore, must be treated immediately. Our case, is a middle-aged female who presented with symptoms and had an exophytic duodenal mass of about 60mm in diameter, microscopically showing tubulo-villous intestinal pattern with high grade dysplasia and no breach in muscularis mucosae, thereby making it a case with distinct presentation and characteristics.

Evaluation of Focused Mini-Incision Parathyroidectomy in Primary Hyperparathyroidism

Abstract Background In the era of effective preoperative localization and availability of intraoperative parathyroid hormone (IOPTH) assay, the trend now in parathyroidectomy is shifting from bilateral neck exploration (BNE) into minimal invasive parathyroidectomy (MIP). The concept of MIP is based on the fact that 85% of cases have single adenoma. This study highlights the outcomes of focused mini- incision parathyroidectomy (FMIP) for the treatment of selected cases of primary hyperparathyroidism. Aim of study: To evaluate and assess the outcome and advantages of focused mini-incision parathyroidectomy in parathyroid adenoma of primary hyperparathyroidism. Patients and Methods This cohort study was conducted at endocrine surgery unit, Ain Shams University Hospital, and Sohag Cancer Institute including 22 patients with benign solitary parathyroid adenoma; 17 retrospective cases &amp; 5 prospective cases. These included patients had been operated with focused mini-incision parathyroidectomy within the time period from January 2018 to December 2020 as retrospective cases and from January 2021 to December 2021 as prospective cases. Results In this study, age ranged from 30 to 70 years with mean age 50.23 ± 10.71 years. The preoperative serum calcium level ranged from 10.8 to 14.2 mg/dl (mean 12.28 ± 1.16 mg/dl). The preoperative parathyroid hormone level was elevated ranging from 256 to 2090 pg/mL (mean 970.68 ± 563.97 pg/mL). In this study, the operative time ranged from 55 to 75 minutes with mean 64.36 ± 6.33 minutes, percentage of IOPTH decrease level ranged from 75-95 % with mean percentage 85.72 ± 6.28 %. There were no cases with intraoperative bleeding or recurrent laryngeal nerve (RLN) injury. Hospital stay ranged from 6-16 days with mean 10.77 ± 3.10 days. There is no wound infection in all cases. All cases reached a success rate up to 100% (decrease the IOPTH level ≥ 75 %, and resolution of preoperative hypercalcemic manifestations). Conclusion Depending to the high successful rate, very low intraoperative morbidity and better postoperative recovery and cosmoses of FMIP technique, it should be the first choice for pHPT cases with solitary parathyroid adenoma, provided by the concordance localization study of U/S and MIBI scan preoperative.

Parathyroidectomy for solitary parathyroid adenoma via trans-areola single site endoscopic approach: Results of a case-match study.

This study aimed to establish the standardized procedure of trans-areola single site endoscopic parathyroidectomy (TASSEP), and to compare the performance of TASSEP with that of conventional open parathyroidectomy (COP). This study enrolled 40 patients with primary hyperparathyroidism (PHPT) who underwent TASSEP, and included 40 of 176 PHPT patients who underwent COP based on propensity score matching. The retrospective analysis was conducted based on prospectively collected data. Perioperative outcomes, including surgical profile, surgical burden and cosmetic results and follow-up were reported. The learning curve was described using a cumulative sum (CUSUM) analysis. 40 TASSEPs were completed successfully without conversions or severe complications. There was no statistically significant difference in operation time between TASSEP and COP groups (80.83 ± 11.95 vs. 76.95 ± 7.30 min, p = 0.084). Experience of 17 cases was necessitated to reach the learning curve of TASSEP. Postoperative pain score and traumatic index (C-reactive protein and erythrocyte sedimentation rate) in TASSEP were apparently lower than those in COP group (p < 0.05). During the proliferation and stabilization phases, TASSEP was associated with significantly better incision recovery and cosmetic scores. Postoperative serum calcium and PTH levels throughout the follow-up period indicated satisfactory surgical qualities in both groups. Based on precise preoperative localization and intraoperative planning facilitated by three-dimensional (3D) virtual modeling, TASSEP can be feasibly performed on selected patients with satisfactory success rates and low complication rates, providing preferable cosmetic results and alleviating the surgical burden to a certain extent.

Unilateral Primary Aldosteronism: Long-Term Disease Recurrence After Adrenalectomy.

Primary aldosteronism (PA) is frequently caused by a unilateral aldosterone-producing adenoma with a PA-driver mutation. Unilateral adrenalectomy has a high probability of short-term biochemical remission, but long-term postsurgical outcomes are relatively undefined. Our objective was to investigate the incidence of long-term recurrence of PA in individuals with postsurgical short-term biochemical remission. Adrenalectomized patients for unilateral PA were included from a single referral center. Histopathology and outcomes were assessed according to international histopathology of unilateral primary aldosteronism and PASO (Primary Aldosteronism Surgical Outcome) consensuses. Genotyping was performed using CYP11B2 (aldosterone synthase)-guided sequencing. Classical adrenal histopathology, exemplified by a solitary aldosterone-producing adenoma, was observed in 78% of 90 adrenals, compared with 22% with nonclassical histopathology. The classical group displayed higher aldosterone-to-renin ratios (P=0.013) and lower contralateral ratios (P=0.008). Outcome assessments at both short (12 months [7; 12]) and long (89 months [48; 124]) terms were available for 57 patients. At short-term assessment, 53 (93%) displayed complete biochemical success (43 classical and 10 nonclassical), but long-term assessment demonstrated biochemical PA recurrence in 12 (23%) with an overrepresentation of the nonclassical histopathology (6 [60%] of 10 nonclassical histopathology versus 6 [14%] of 43 classical histopathology; P=0.005). PA-driver mutations were identified in 97% of 64 aldosterone-producing adenomas; there was no association of the aldosterone-producing adenoma genotype with PA recurrence. A substantial proportion of individuals display postsurgical biochemical recurrence of PA, which is related to the histopathology of the resected adrenal gland. These findings emphasize the role of histopathology and the requirement for continued outcome assessment in the management of surgically treated patients for PA.

Preoperative Preparation in Hyperthyroidism and Surgery in the Hyperthyroid State.

Hyperthyroidism is a clinical condition that develops due to the excessive production and secretion of thyroid hormones by the thyroid gland, leading to an elevated concentration of thyroid hormones in tissues. Hyperthyroidism is characterized by low TSH and elevated T3 and/or T4, with the most common causes being Graves' disease, toxic multinodular goiter, and solitary toxic adenoma. T3 is the peripherally active form of thyroid hormone, affecting nearly each tissue and system. The most prominent aspects of hyperthyroidism are related to the cardiovascular system. The treatment of hyperthyroidism includes three options: antithyroid drugs (ATDs), radioactive iodine therapy (RAI), and surgery. Among these treatment modalities, surgery is considered as the most effective one. For patients who are candidates for surgery, preoperative preparation is required to ensure that the thyroidectomy can be performed under optimal conditions. Preoperative preparation should be a combination therapy aimed at preventing the synthesis, secretion, and peripheral effects of thyroid hormones from the thyroid gland. Medications that can be used in this treatment include thionamides, beta-blockers, iodine, corticosteroids, cholestyramine, perchlorate, lithium, and therapeutic plasma exchange. These treatment options can be combined based on the patient's condition. While it is recommended that patients be made euthyroid through preoperative antithyroid treatment to prevent the feared complication, which is the thyroid storm, the supporting evidence is limited. Preoperative treatment does not prevent against thyroid storm whether the patient is euthyroid or hyperthyroid during surgery. Whether surgery should be delayed until biochemical euthyroidism is achieved in hyperthyroid patients remains a topic of debate. Recent studies suggest that thyroidectomy can be safely performed during the hyperthyroid phase by experienced anesthesiologists and surgeons without precipitating thyroid storm or increasing intraoperative and postoperative complications. Although achieving the euthyroid state before surgery is ideal in hyperthyroid patients, it is not always possible. Factors such as allergies to medications, drug side effects, treatment-resistant disease, patient noncompliance, and the urgency of definitive treatment are critical in determining whether hyperthyroidism can be controlled preoperatively. When surgery is necessary in hyperthyroid patients without achieving euthyroidism, the patient's overall condition and comorbidities should be evaluated together by the anesthesiologist, surgeon and endocrinologist, with particular attention to stabilizing the cardiovascular system. We believe that in hyperthyroid patients who are cardiovascularly stable during the hyperthyroid phase, thyroid surgery may not need to be delayed and can be performed safely.

Correlation of Histopathologic Subtypes of Primary Aldosteronism with Clinical Phenotypes and Postsurgical Outcomes.

Clinical implications of unilateral primary aldosteronism (PA) histopathology remain to be determined in various ethnic populations. We examined the histopathology of unilateral PA using CYP11B2 immunostaining in relation to clinical phenotypes and postsurgical outcomes. Patients consecutively operated for unilateral PA from 2010 to 2020 at 3 tertiary hospitals in South Korea were retrospectively enrolled. Adrenals with solitary aldosterone-producing adenomas and/or dominant aldosterone-producing nodules were classified as the classical and the others as the nonclassical groups. The classical group was subdivided into mixed or solitary group according to whether other aldosterone-producing lesions coexist or not. Of the 240 cases, 124 were solitary, 86 mixed, and 30 nonclassical. Baseline serum potassium concentration was lower in the solitary group than the mixed or nonclassical group. Plasma aldosterone concentration after saline loading was the highest in the solitary group (median 31.65 ng/dL), followed by the mixed group (median 25.40 ng/dL), and the lowest in the nonclassical group (median 14.20 ng/dL). Solitary and mixed groups showed higher lateralization indices and lower contralateral indices than the nonclassical group. The contralateral index was lower in the solitary group than the mixed group. At 6 to 12 months after adrenalectomy, fewer antihypertensive medications were required for the solitary and mixed groups than the nonclassical group. The solitary group, followed by the mixed group, was associated with more severe hyperaldosteronism and more suppressed aldosterone production from the contralateral side than the nonclassical group. Histopathologic phenotypes were related to the clinical manifestations and may suggest postoperative prognosis.

Parathyroid adenoma: multimodal diagnosis capabilities: A retrospective study

Background. Primary hyperparathyroidism is a common endocrinological disease caused mainly by parathyroid adenoma. The main treatment method is surgery (parathyroidectomy). Therefore, the exact determination of adenoma localization is crucial.&#x0D; Aim. To evaluate the current possibilities of multimodal diagnosis of parathyroid adenomas.&#x0D; Materials and methods. A retrospective analysis of 49 patients with primary hyperparathyroidism aged 24 to 82 (median 57.9 years) was performed. Modern radionuclide and hybrid technologies were used for topical diagnosis and metabolic assessment of parathyroid adenomas: scanning, single-photon emission computed tomography, single-photon emission computed tomography combined with computed tomography, positron emission tomography combined with computed tomography with 18F-deoxyglucose and 18F-choline. The diagnosis of primary hyperparathyroidism was confirmed by a biochemical blood test: the level of parathyroid hormone and ionized and total calcium.&#x0D; Results. The study included 43 (87.8%) females and 6 (12.2%) males. The female/male ratio was 7.2:1. Most cases (78.1%) were the hypercalcemic type of primary hyperparathyroidism, and the normocalcemic type was diagnosed in 21.9% of patients. The mean parathyroid hormone level was 145.43 pg/mL, exceeding the reference values by 2.2 times. Parathyroid hormone concentration in patients with primary hyperparathyroidism was 156.38 pg/mL, and mean ionized and total blood calcium levels were 1.43 and 3.04 mmol/L, respectively. The asymptomatic type occurred in 76.7% of patients. The symptomatic type of hyperparathyroidism had 23.3%, manifested with nephrolithiasis, pancreatitis, and bone lesions. Parathyroid adenomas were more often located in the left lobe (42.9%). In 77.6% of patients with primary hyperparathyroidism, solitary adenomas were detected. Ectopia of the parathyroid glands was detected in 16.3% of patients, with intrathyroidal location in the left lobe being the most common. Rare locations include the anterior and posterior mediastinum and the esophageal wall.&#x0D; Conclusion. Modern diagnostic multimodal options based on radionuclide and hybrid technologies are crucial in the personalized treatment of primary hyperparathyroidism.

GIANT PARATHYROID ADENOMA - A DIFFICULT DIAGNOSIS OR A LACK OF SPECIALIST TRAINING?

A clinical observation of a 48-year-old patient with a giant adenoma of the left lower parathyroid gland is presented. Peculiarities of preoperative planning of asymmetrical mini-access on the anterior surface of the neck and methodology of intraoperative optimization of the key parameters of surgical access in the process of tumor mobilization are shown. Considering the difficulties arising in the process of diagnostics and treatment of the disease, importance of additional information of wide range of specialists concerning clinical manifestations, peculiarities of diagnostics and treatment of patients with primary hyperparathyroidism on the background of the solitary parathyroid adenoma is pointed out. The expediency of additional specialization of surgeons within the framework of the multidisciplinary specialty "Surgical Cervicology", previously proposed by the authors, is emphasized.

Radiofrequency ablation for autonomously functioning nodules as treatment for hyperthyroidism: subgroup analysis of toxic adenoma and multinodular goitre and predictors for treatment success

PurposeTreatment of hyperthyroidism caused by autonomously functioning thyroid nodules (AFTN) with 131I often leads to undesirable hypothyroidism. Radiofrequency ablation (RFA) has emerged as a promising alternative. This retrospective analysis aimed to examine the efficacy of, and postprocedural hypothyroidism after, RFA for AFTN.MethodsPatients with hyperthyroidism caused by AFTN and treated with RFA were included if follow-up of at least 1 year was available. Cure was defined as thyroid medication–free biochemical euthyroidism. To predict cure, patient and treatment factors were analysed. A distinction was made between solitary toxic adenoma (STA) and toxic multinodular goitre (TMG).ResultsForty-eight patients (36 STA, 12 TMG) were included. One year post-RFA cure rate was 72% in STA versus 25% in TMG (p = 0.004). One patient developed hypothyroidism. In 11 patients that remained hyperthyroid, a second RFA was successful in 83% of STA and 40% of TMG patients. At last available follow-up, this amounted to a total cure rate of 81% in STA and 33% in TMG (p = 0.002). In STA, cured patients had a higher baseline TSH and a lower FT3 than non-cured patients (p = 0.026 and 0.031). Cure was observed in 91% of patients when > 2.1 kJ/mL was delivered during RFA, compared to 44% when less energy was administered.ConclusionThe efficacy of RFA was nearly 3 times higher in STA patients compared to TMG. Severity of hyperthyroidism and kJ/mL delivered during RFA predicts cure. Direct comparison to the current standard of care is needed to implement RFA in treatment of hyperthyroidism caused by AFTN.

Adrenal Vein Sampling in the Young - Necessary or Not?

Current clinical guidelines from the US Endocrine Society state that adrenal venous sampling (AVS) may not be necessary in patients younger than 35 years with marked aldosteronism and a solitary adrenal adenoma on imaging. At the time when the guidelines were published, only one study supported the statement, a study that included 6 patients younger than 35 years, all of whom had unilateral adenoma on imaging and unilateral primary aldosteronism (PA), according to AVS. Since then, to our knowledge, four additional studies have been published that provide data on concordance between conventional imaging and AVS among patients younger than 35 years. In these studies, 7 of 66 patients with unilateral disease on imaging had bilateral disease, according to AVS. We find it, therefore, reasonable to conclude that imaging studies alone inaccurately predict laterality in a significant number of young patients with PA and that available data challenge the current clinical guidelines.

The role of calcium sensitive and vitamin D receptors in the pathogenesis of sporadic multiple parathyroid gland disease

Sporadic multiple parathyroid gland disease is ¼ cases of primary hyperparathyroidism (PHPT). However, a single tactic for diagnosing and operating volume in patients with this variant of PHPT has not yet been developed. One of the possible directions in the search for pathogenetically substantiated methods of diagnosis and treatment is the study of the molecular genetic features of the disease and associated clinical and laboratory factors. To study the features of the expression of calcium sensitive (CaSR) and vitamin D (VDR) receptors on the surface of parathyroid cells in primary hyperparathyroidism with solitary and multiple lesions of the parathyroid glands, as well as its changes under the influence of a decrease in the filtration function of the kidneys. In a single center observational prospective study with retrospective data collection, there were patients who during 2019-2021. operated on for PHPT, secondary hyperparathyroidism (SHPT) and all cases of tertiary hyperparathyroidism (THPT) operated during 2014-2021. The expression of CaSR, VDR and its relationship with the main laboratory parameters, the clinical variant of hyperparathyroidism, and the morphological substrate were studied. The study included 69 patients: 19 with multiple and 25 with solitary PTG near PHPT, 15 with SHPT, 10 with THPT. A statistically significant decrease in the frequency of detection of normal expression of CaSR and VDR receptors occurs in any morphological variant of hyperparathyroidism and is observed in 93-60% of drugs. A decrease in the normal expression of CaSR in hyperplasia is detected statistically significantly less frequently than in adenoma (p≤0.01). The median expression intensity in adenoma was 2.5 (2:3), in hyperplasia 3.5 (3-4) (p≤0.01). The difference in the molecular mechanisms of the development of hyperparathyroidism with a predominance of a morphological substrate in the form of adenoma (PHPT with solitary adenoma) or hyperplasia (SHPT and PHPT with multiple PTG lesions) is realized in the frequency of maintaining normal CaSR expression in the PTG tissue. These mechanisms are implemented at the local level, their variability does not change under the influence of RRT. A common molecular genetic mechanism for the development of hyperparathyroidism with a predominance of a morphological substrate in the form of adenoma or hyperplasia has been found to reduce the frequency of maintaining normal VDR expression in PTG (up to 7-13%), p&lt;0.01. This mechanism is implemented at the local level, its variability changes under the influence of RRT, reaching statistically significant differences in patients with THPT. The study demonstrates the features of changes in the expression of CaSR and VDR in PHPT with multiple lesions of the parathyroid glands. The relationship between the expression of these receptors and the clinical variant of hyperparathyroidism, the morphological substrate, the main laboratory parameters, and renal function was shown.

Abstract #1398160: A Rare Case of Water Clear Cell Parathyroid Adenoma Escaping Sestamibi Scan and Neck Ultrasound – A Diagnostic Conundrum of a Rare Pathological Intity with a Rare Presentation

Parathyroid water-clear cell hyperplasia (WCCH) and water-clear cell adenoma (WCCA) are extremely rare causes of primary hyperparathyroidism (PHPT). WCCH contributes to < 1% of all PHPT however WCCA is exceptionally rare and has been reported only in less than 30 case reports. We are presenting a very rare indolent pathological entity with a very rare presentation escaping common diagnostic measures of Sestamibi scan and neck ultrasound. A 63-year-old female presented for evaluation of severe osteoporosis with a T-score of -3.6. Laboratory workup revealed elevated parathyroid hormone (PTH) of 122 pg/ml (reference range 12-88 pg/ml), Normal calcium 9.8 mg/dl, Normal vitamin D 50 ng/ml, and normal magnesium 2.2 mg/dl. 24-hour urine calcium was 421 mg/24H. Diagnosis was consistent with normocalcemic PHPT and meeting surgical criteria with osteoporosis and high urine calcium. Sestamibi scan did not identify any focal activity. CT H&N revealed an 8 mm mass inferior and posterior to right thyroid lobe with partial washout and slightly different enhancement compared to thyroid gland. Neck ultrasound (US) reported that previously noted tissue activity on the CT H&N is not visualized and most likely represents normal thyroid tissue. Patient was referred to otolaryngology surgery and underwent four gland explorations, including right inferior and left superior parathyroidectomy. Pathology of superior parathyroid gland revealed parathyroid water clear cell adenoma. 3-month Postoperative PTH 29.4 pg/ml and calcium level of 9.3 mg/dl. Solitary parathyroid adenoma (SPA) attributes to 80-85% of PHPT. Majority of cases is due to Chief cell adenomas, less frequent pathologies include oxyphil cell adenoma, lipoadenoma, WCCA or mixed type. Scientific literature regarding WCCA presentation and diagnosis is blurred due to its rarity. Clinical presentation of WCCA resembles other etiologies of PHPT, though some data suggest that is frequently indolent and manifests with mild PHPT. Literature suggests that WCCA has low biochemical activity and most cases had normal to mildly elevated calcium-our patient support this hypothesis-. Hypercalcemia does not manifest until significant growth of the adenoma, though few reported cases manifested with hypercalcemia. Unlike other SPA where Sestamibi scan sensitivity is 91%, literature suggests possibility of false-negative results with WCCA which is hypothesized to be attributed to its different histology of glycogen-rich vacuolized cytoplasm that leads to fast Sestamibi wash-out, for the same reason data suggest that US is more decisive given high water content of cells -Our patient didn’t follow this rule and escaped Sistamibi and US though seen on CT- which still makes the diagnosis of WCCA a conundrum. Some cases underwent surgical excision based on clinical diagnosis which led to revision of PHPT and/or hypercalcemia. There is no available data suggesting different long-term follow-up regimens for WCCA compared to other SPA. Further literature with longer follow-up is needed for this extremely rare entity for a comprehensive understanding of its natural course.

Multi-modality parathyroid imaging: A shifting paradigm.

The goal of parathyroid imaging in hyperparathyroidism is not diagnosis, rather it is the localization of the cause of hyperparathyroidism for planning the best therapeutic approach. Hence, the role of imaging to accurately and precisely localize the abnormal parathyroid tissue is more important than ever to facilitate minimally invasive parathyroidectomy over bilateral neck exploration. The common causes include solitary parathyroid adenoma, multiple parathyroid adenomas, parathyroid hyperplasia and parathyroid carcinoma. It is highly imperative for the radiologist to be cautious of the mimics of parathyroid lesions like thyroid nodules and lymph nodes and be able to differentiate them on imaging. The various imaging modalities available include high resolution ultrasound of the neck, nuclear imaging studies, four-dimensional computed tomography (4D CT) and magnetic resonance imaging. Contrast enhanced ultrasound is a novel technique which has been recently added to the armamentarium to differentiate between parathyroid adenomas and its mimics. Through this review article we wish to review the imaging features of parathyroid lesions on various imaging modalities and present an algorithm to guide their radiological differentiation from mimics.

Transoral Thyroidectomy: Initial Results of the European TOETVA Study Group

BackgroundThe aim of this study was to evaluate a new surgical technique by the European Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) Study Group.MethodsThis study included 391 patients (47 [(12%]) male and 344 [(88%)] female) who had undergone endoscopic thyroid or parathyroid surgery via the vestibular approach between February 2016 and May 2022 at nine centers. The data were analyzed with regard to complications, surgery time and specimen retrieval.ResultsOverall, 376 (96.2%) TOETVA and 15 (3.8%) transoral endoscopic parathyroidectomy vestibular approach interventions were performed with an average surgery time of 145 (± 61.2) minutes and 509 nerves at risk. The specimens were retrieved via a transoral vestibular and retroauricular approach in 66 (16.9%) patients and via a transaxillary approach in 8 (2%). Benign histology including Grave’s disease was identified in 272 (69.6%) patients, 1 (0.3%) presented noninvasive follicular thyroid neoplasms with papillary-like nuclear features, and 103 (26.3%) showed differentiated thyroid carcinoma. Solitary parathyroid adenoma were removed in 15 (3.8%) patients. Conversion to open surgery was necessary in 13 (3.3%) and revision had to be performed in 2 (0.5%) patients. Transient recurrent laryngeal nerve palsy (RLNP) was present in 18 (4.6%) and permanent RLNP in 2 (0.5%) patients. Fifteen (3.8%) patients experienced transient hypoparathyroidism after thyroidectomy. No case of permanent hypoparathyroidism was observed. Postoperative surgical site infection occurred in 1 (0.3%) patient. Despite a higher rate of sensory and motor disorders and skin discoloration at discharge, permanent disorders were present in only 3 (0.8%) and 16 (4.1%) patients, respectively.ConclusionOur results show that transoral endoscopic surgery, performed by experienced endocrine surgeons, is a safe alternative to conventional thyroid surgery.

Network-medicine approach for the identification of genetic association of parathyroid adenoma with cardiovascular disease and type-2 diabetes.

Primary hyperparathyroidism is caused by solitary parathyroid adenomas (PTAs) in most cases (⁓85%), and it has been previously reported that PTAs are associated with cardiovascular disease (CVD) and type-2 diabetes (T2D). To understand the molecular basis of PTAs, we have investigated the genetic association amongst PTAs, CVD and T2D through an integrative network-based approach and observed a remarkable resemblance. The current study proposed to compare the PTAs-associated proteins with the overlapping proteins of CVD and T2D to determine the disease relationship. We constructed the protein-protein interaction network by integrating curated and experimentally validated interactions in humans. We found the $11$ highly clustered modules in the network, which contain a total of $13$ hub proteins (TP53, ESR1, EGFR, POTEF, MEN1, FLNA, CDKN2B, ACTB, CTNNB1, CAV1, MAPK1, G6PD and CCND1) that commonly co-exist in PTAs, CDV and T2D and reached to network's hierarchically modular organization. Additionally, we implemented a gene-set over-representation analysis over biological processes and pathways that helped to identify disease-associated pathways and prioritize target disease proteins. Moreover, we identified the respective drugs of these hub proteins. We built a bipartite network that helps decipher the drug-target interaction, highlighting the influential roles of these drugs on apparently unrelated targets and pathways. Targeting these hub proteins by using drug combinations or drug-repurposing approaches will improve the clinical conditions in comorbidity, enhance the potency of a few drugs and give a synergistic effect with better outcomes. This network-based analysis opens a new horizon for more personalized treatment and drug-repurposing opportunities to investigate new targets and multi-drug treatment and may be helpful in further analysis of the mechanisms underlying PTA and associated diseases.