Solitary Adenoma Research Articles

Investigating Unexpected Shortening of Height of A Middle-Aged Woman: A Case Report

Osteitis fibrosa cystica (OFC) is a late sequela of untreated hyperparathyroidism caused by the autonomous secretion of parathyroid hormone (PTH). It is characterized by bone pain, skeletal deformities, and pathological fractures. OFC is caused by hypersecretion of PTH, leading to demineralization of bone and pathological fractures. We report a case of unusual presentation of OFC in a middle aged woman who noticed gradual shortening of her height within a particular period of time. Apart from height reduction, the patient had weight loss and pain in different parts of the body for over a decade. Despite being treated with analgesics and steroids initially, there was no significant improvement in her condition. Treatment history included surgical reduction of right elbow fracture and empirical anti-tubercular drug twice as there was a suspicion of disseminated tuberculosis. The patient developed lytic changes, skeletal deformities, and osteoporosis, and was diagnosed with a solitary parathyroid adenoma on the right side. Bangladesh J. Nuclear Med. 26(1): 58-61, 2023

Mask parathyroid adenoma in morbid obese woman with secondary adrenal insufficiency

Abstract Introduction Primary hyperparathyroidism (PHPT) and metabolic syndrome (MS) are independently increase cardiovascular morbidities; however, this association is still controversial. The pathogenic mechanisms of MS among PHPT are not completely clear and the association with calcium metabolism is being studied, since calcium is pivotal for many metabolic processes. The association between these entities is complex and may be a source of additional morbidity and mortality. Objective is to highlight the mask features of parathyroid adenoma in morbid obese woman with secondary adrenal insufficiency. Clinical case A 33-year-old female presented with discomforting polyarthralgia and weight gain for the last 2 years that was labelled as nonspecific arthritis and treated by multiple intra-articular injections of glucocorticoids. After a careful history and examination with baseline analysis, she was discovered to have MS (dysglycemia, high insulin resistance and hypertension). A feature glucocorticoid induced adrenal insufficiency was documented and work up for any evidence of osteoporosis was initiated. A high parathyroid hormone with hypercalcemia was documented and an established osteoporosis was evident. Furthermore, a large left side parathyroid adenoma was observed by a neck sonography and confirmed by a four-dimension computed tomography of the neck. Surgical exploration with excision of the parathyroid adenoma was performed, following which the patient recovered uneventfully. The patient was initially managed as a case of MS with secondary adrenal insufficiency due to glucocorticoid misuse. Although not suspected initially, an extensive work up for osteoporosis screening and accidental hypercalcemia increase the chance of high index of suspicion for hyperparathyroidism. Further investigations then revealed the presence of a solitary parathyroid adenoma with coexistent hyperparathyroidism which was then managed surgically. Conclusion Despite the majority of PHPT is asymptomatic and over masked by MS, Active surveillance for any evidence of hypercalcemia and bone metabolism have to be judged carefully to reduce further morbidity and mortality.

Main parathyroid tumors

Primary hyperparathyroidism is the third most common disease of the endocrine system. It is characterized by an increase in parathyroid hormone, hypercalcemia, hypercalciuria, hypophosphatemia. Symptoms include polyuria, bone pain, weakness, and constipation. In most cases, primary hyperparathyroidism is caused by solitary parathyroid adenoma — 85%. Other causes include hyperplasia (5%), multiple adenomas (<5%), and cancer (<1%). However, particular attention in this article is paid to two causes of primary hyperparathyroidism: parathyroid adenoma and cancer, as they are of high interest both from a molecular point of view and from the clinical features of these tumors. In addition, these tumors overlap in their symptoms and signs and the diagnosis is often made only after histological examination. In total, we identified 2700 articles, of which 66 met the inclusion criteria. The 66 included studies were topical for tumor lesions of the parathyroid gland. They were held between 1997 and 2022. This review emphasizes the importance of further research of the molecular features of these diseases and, possibly, targeted treatment options, since, for example, in cancer, even with R0 resection, the risk of recurrence is high. The article also focuses on the issues of the new World Health Organization 2022 classification of tumor lesions of the parathyroid gland, which is also important for a unified study of these tumors.

PS-R03-8: PARATHYROID ADENOMA PRESENTING AS UNEXPLAINED SINUS TACHYCARDIA AND REFRACTORY HYPERTENSION: A CASE REPORT

Introduction: Primary hyperparathyroidism (PHPT) and malignancy account for most cases of hypercalcemia in clinical practice. They commonly occur in relation to a solitary parathyroid adenoma, parathyroid hyperplasia, or carcinoma. Majority of patients are asymptomatic, although some present with vague unusual symptoms. Case: We report a case of a 50-year-old lady presenting with unexplained resting tachycardia, uncontrolled hypertension and generalised ill-health for one year in the background of complicated type 2 diabetes, dyslipidaemia, and hypertension. She had marginally elevated serum ionized calcium with normal serum phosphate levels in the background of early chronic kidney disease. Intact parathyroid hormone level was elevated with concomitant low levels of vitamin D. Clinical evaluation revealed an anterior neck lump which was ultrasonically suspected as a thyroid enlargement with possibility of a deep-seated parathyroid mass. A sestamibi B scan confirmed the presence of a single parathyroid adenoma. The possibility of Multiple Endocrine Neoplasia (MEN) was ruled out. She underwent a successful partial thyroidectomy with removal of the parathyroid mass. Histology revealed a solitary benign parathyroid adenoma. Following surgery, her calcium levels returned to normal range and her unexplained tachycardia had settled, as well as her general wellbeing. Her blood pressure was controlled with 3 antihypertensive drugs. Discussion: Hypercalcemia should be suspected as a rare possibility in the workup of unexplained sinus tachycardia and hypertension, and could be masked with concomitant vitamin D deficiency.

Correlation between preoperative calcium and parathormone levels with parathyroid gland volume.

Objective. Hyperparathyroidism is a prevalent disease with parathyroid adenomas being the most common cause. Surgical excision remains the standard treatment for parathyroid adenoma. Successful preoperative localization of the parathyroid adenoma could facilitate the decision regarding the extent of surgical exploration. The aim of the current study was to assess the correlation between the preoperative values of parathyroid hormone and ionized calcium with the adenoma weight and volume in patient with primary hyperparathyroidism caused by single-gland adenoma. Patients and Methods. We did this retrospective review for all patients who were diagnosed with primary hyperparathyroidism due to a solitary parathyroid adenoma in our general surgery department over 4 years. SPSS software was used to get the correlation coefficient between the peak preoperative levels of calcium and parathyroid hormone with the parathyroid adenoma weight and volume. Results. Ninety-nine patients were included into the study. The average age at surgery was 62.65±12.00 years. The correlation coefficient between the adenoma volume and weight with the preoperative ionized calcium level was weakly positive (r=0.329, p<0.01) and (r=0.281, p=0.019), respectively, while the correlation with the preoperative parathyroid hormone level was stronger (r=0.708, p<0.01) and (r=0.650, p<0.01), respectively. Conclusions. The strong positive relationship between the preoperative parathyroid hormone and calcium levels with the parathyroid adenoma size and weight can help the surgeon to predict the volume of the involved gland and avoid an unnecessary dissection.

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.

Does the sonography-scintigraphy correlation affect the success of minimally invasive parathyroid Surgery? Results from a single center

In patients with primary hyperparathyroidism, complete surgical resection of all hyperfunctioning parathyroid tissue is essential. The aim of this study was to evaluate the success rates of minimally invasive parathyroidectomies for primary hyperparathyroidism performed after localization studies with 99mTc-sestamibi (MIBI) scintigraphy and neck ultrasonography (USG). And also, we aimed to determine the factors affecting the success rate in surgery. Retrospective analysis of 58 consecutive patients with a diagnosis of primary hyperparathyroidism who underwent parathyroidectomy between January 2018 and December 2021 in our institution. The patients were evaluated according to Miami criteria and divided into two groups as successful or unsuccessful surgery. Demographic and clinical characteristics of the patients were obtained from hospital records. Surgical success was achieved in 50 (86.2%) of the 58 patients included in the study. In both groups, neck USG and MIBI scintigraphy showed the same localization for the lesion in a correlated manner. The clinical complaints of the patients, preoperative PTH, Ca and 24-hour urinary Ca levels were similar in both groups. In 10 (17.2%) patients, inconsistency in localization was found between USG and MIBI scintigraphy, and surgical failure was found in 4 (40%) of these patients. Surgical failure was statistically significant in patients with inconsistency in localization between USG and MIBI scintigraphy. The sono-scintigraphic scan concordance increases surgical success rates in cases where minimally invasive parathyroid surgery is planned. If there is an inconsistency between USG and MIBI, preoperative four dimentional computed tomography, intraoperative rapid PTH, gamma probe or frozen method can be used. It should be kept in mind that multiple gland pathologies may be more common in addition to solitary adenoma in lesions smaller than 1 cm in USG. In addition, in these cases, as the diagnostic value of scintigraphy is low, surgical success will also decrease.

Difficulties of diagnostics of parothoid adenoma in the background of combined treatment of advanced thyroid cancer

In clinical practice, the most common sporadic variant of solitary parathyroid adenoma. Atypical adenomas of the parathyroid glands are a rare form and present the greatest difficulty in determining the potential for malignancy, the extent of surgical treatment, and the patients dynamic follow-up regimen. They are not characterized by the classic signs of malignant growth invasion beyond the formation capsule or the presence of metastases. Specific clinical and prognostic phenotypes of parathyroid adenomas are highly individual.&#x0D; No more than 3% of parathyroid adenomas are associated with papillary thyroid cancer. Awareness of such a combination of pathology allows us to assess possible risks and determine the scope of surgical intervention as the only method of radical treatment of pathologically altered parathyroid tissue. With early detection of recurrence of thyroid cancer, it is necessary to conduct additional monitoring of hormonal activity and radiation diagnosis of tumor pathology of the parathyroid glands.&#x0D; The presented clinical case showed that the cytological and histological diagnosis of parathyroid adenoma against the background of recurrence of advanced thyroid cancer can fundamentally differ at different stages of the morphological study. With parathyroid adenoma in the preoperative period, there may be a discrepancy between these methods of radiation and intraoperative diagnostics and the results of an urgent and planned histological examination. The uncharacteristic course of solitary parathyroid adenoma after thyroidectomy in combination with false positive results due to ultrasound location of thyroid nodules (residual tumors and cancer recurrences, as well as paratracheal metastases) and nervous tissue (paraganglioma) contributes to incorrect preoperative diagnosis of thyroid bed tumors. At the preoperative stage of diagnosing tumor pathology of the parathyroid glands, it is advisable to perform scintigraphy of the parathyroid glands with a simultaneous combination of ultrasound, which will increase the sensitivity of the diagnosis.&#x0D; After surgical treatment of tumor pathology of the parathyroid tissue, in some cases, the result of differential diagnosis is an immunohistochemical study to form a final diagnosis and determine further patient management tactics.

ODP098 Hyperparathyroidism Caused by Two Large Water Clear Cell Adenomas

Abstract Background In ambulatory settings, primary hyperparathyroidism is the most prevalent cause of hypercalcemia. Approximately 85% of primary hyperparathyroidism cases are caused by a solitary parathyroid adenoma; other causes include diffuse parathyroid hyperplasia, multiple parathyroid adenomas, and parathyroid cancer. Chief cell adenomas are the most prevalent; adenomas can also consist of oxyphil cell adenomas, lipoadenomas, or mixed cell adenomas. Water clear cell adenoma (WCCA) is a rare tumor formed of large clear cells with foamy pink cytoplasm. Fewer than 30 cases have been recorded in the literature. Case A 52-year-old male with polyuria and polydipsia, diagnosed with hypercalcemia was referred to an endocrinologist. His calcium was 10.9 mg/dl, corresponding parathyroid hormone (PTH) 74 pg/ml, 24-hour urine calcium 818 mg/24hr, vitamin D 25–hydroxy 24.2 ng/ml. He was referred to an endocrine surgeon. A 4-dimensional CT scan revealed soft tissue masses posterior to the thyroid and in the tracheoesophageal groove, consistent with potential parathyroid masses. In the operating room, baseline intraoperative PTH (ioPTH) was 371 pg/ml. A large left superior gland was removed from its normal position, and the ioPTH dropped to 104 pg/ml at 10 minutes post-resection, followed by a rise to 525 pg/ml. A large descended (ectopic) right superior gland was then identified and resected, and the ioPTH decreased to 72, 44, and 57 pg/ml at 10, 15 and 20 minutes post-resection. The remaining parathyroid glands were not identified due to adipose tissue in the neck and likely gland suppression in the setting of high PTH. The pathology report of the two excised glands (left superior 3.2×1.7×0.5cm and 3.703g, right superior 3.4×1.3×0.4cm and 1.86g) demonstrated water clear cell tissue. Post-operatively, patient's polyuria and polydipsia resolved. Labs collected 3 months after surgery demonstrated normalization of the calcium and PTH. The patient was advised to continue follow up every six months. Conclusion Water clear cell parathyroid adenomas are extremely rare. Water clear-cell lesions are considered indolent because excised adenomas are markedly larger than conventional adenomas and grow to a considerable size before becoming biochemically active and diagnosed. Clinical presentation of water clear cell parathyroid lesion is like other causes of primary hyperparathyroidism. The only way to diagnose is via histopathological examination. In rare cases, clear cell renal carcinoma can metastasize to the parathyroid gland causing a similar presentation. Additionally, the rate of hypercalcemia recurrence is higher in WCCA as compared to chief cell adenoma. Therefore, closer follow up of these patients is recommended. Reporting additional cases will aid in our understanding of this uncommon entity, elucidating possible causes/associations, natural history, typical appearances, and post-treatment prognosis. Presentation: No date and time listed

Case of clinically "aggressive" course of primary hyperparathyroidism, algorithm of differential diagnosis

Primary hyperparathyroidism (PHPT) is a significant endocrine disease caused by increased production of parathyroid hormone (PTH) by altered parathyroid glands and violation of the mechanisms of regulation of serum calcium concentrations. These changes can lead to nephrolithiasis, osteoporosis, erosive and ulcerative lesions of the gastrointestinal tract, a number of less specific symptoms (nausea, vomiting, weakness, fatigue, etc.). Etiologically, in more than 85% of cases, PHPT is a consequence of sporadic solitary adenoma or hyperplasia parathyroid glands, however, in 1-3% of cases, the cause is carcinoma of parathyroid glands , including as part of various genetic syndromes. The importance of timely examination for PHPT of patients with characteristic clinical manifestations of this disease and - with an aggressive course - alertness towards carcinomas of parathyroid glands was noted. At the same time, the severity of the clinical picture and even the presence of suspicious signs characteristic of hereditary forms of carcinomas of parathyroid glands are not always a consequence of the malignant process. We present a description of a young patient with a severe course of PHPT, multiple fractures and a voluminous tumor of the upper jaw, developed as a result of a typical adenoma of parathyroid glands. Additionally, the algorithm of pre- and postoperative differential diagnosis for such patients is highlighted.

295 Open Minimally Invasive vs Video-Assisted Minimally Invasive Parathyroidectomy for Solitary Adenomas: A Systematic Review and Meta-Analysis

Abstract Aim To conduct a meta-analysis comparing two minimally invasive techniques; Video Assisted Minimally Invasive Parathyroidectomy (VAMIP) and Open Minimally Invasive Parathyroidectomy (OMIP). Method A systematic review and meta-analysis were carried out in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. Databases from MEDLINE, EMBASE, CINAHL identified Randomised Controlled Trials (RCTs), cohort and observational studies that compared VAMIP and OMIP. The primary outcome measures assessed were the VAS score 24 hours after surgery, conversion of the operation to open, failure rates and analgesic consumption. Secondary outcomes were operative time, hospital stay length, and scar length. These studies' data were extracted and statistically analysed. Results The literature search yielded 104 studies of which 4 were included, enrolling 903 patients in this analysis. A significant difference was found regarding rates of conversion to open parathyroidectomy between the two groups, with the OMIP group demonstrating fewer conversions (MD= 3.52, CI= (2.04–6.08), P&amp;lt; 0.00001). No statistically significant differences were found between the two groups when comparing VAS score post-op 24hrs (MD= -1.75, CI= (-9.8–6.3) P= 0.67), consumption of analgesia (OR= 0.49, CI= 0.07–3.54, P=0.48) or failure rates (OR= 1.81, CI= 0.58–5.72, P= 0.31). OMIP had quicker operative times and similar complication rates and scar lengths to MIVAP. Conclusions OMIP was seen to require less need to convert to open parathyroidectomy with shorter operative times and similar complication rates and scar lengths to MIVAP. More studies are required to evaluate the superior technique for parathyroidectomy.

Abstract #1164900: Ectopic Retropharyngeal Parathyroid Adenoma Causing Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that affects approximately 1-7 cases in every 1000 adults. PHPT mostly presents as a sporadic disease (90%) but may be part of hereditary syndromes. A solitary adenoma is found in > 80% of cases while hyperplasia of all four glands is rare (< 15%).

Abstract #1180511: Primary Hyperparathyroidism- Indian data

Primary hyperparathyroidism is the overproduction of parathyroid hormone (PTH) resulting in abnormal calcium in the blood with an associated low phosphate levels. It is not common with a frequency of occurrence of 66 per 100,000 person years in women and 25 per 100,000 person years in men. The mean age at diagnosis is 52 to 56 years. The most common cause is a solitary adenoma.

Radioiodine treatment outcome by dosimetric parameters and renal function in hyperthyroidism

BackgroundHyperthyroidism has been treated with radioiodine therapy for eight decades, with known benefits and side-effects. No consensus exists on which activity dosage and pre-therapeutic measurements are required for optimal treatment, balancing risk of incomplete response, therapy-induced hypothyroidism and radiation exposure. A retrospective analysis was performed to assess these questions.MethodsData was collected on radioiodine treatment outcomes for 904 patients treated for Graves' disease or toxic nodular goitres at our institution during 2016–2020. The prescribed absorbed doses were 120 Gy (Graves’ disease), 200 Gy (toxic multinodular goitre) and 300 Gy (solitary toxic adenoma). Univariate analysis and multivariate regression modelling were used to find factors linked to treatment outcome.ResultsThe cure rate of hyperthyroidism after one administration of radioiodine was 79% for Graves' disease, 94% for toxic multinodular goitre and 98% for solitary toxic adenoma. Thyroid mass, uptake and effective half-life were all significantly associated with cure in Graves’ disease, but not in toxic multinodular goitre. The rates of therapy-induced hypothyroidism were 20% and 29% for toxic multinodular goitre and solitary toxic adenoma. Neither the cure rate nor the hypothyroidism rate was found to be superior among patients with individualised effective half-life measurements in toxic nodular goitres. Poor renal function was associated with dubious iodine uptake measurements but was not found to correlate with worse outcome.ConclusionsMultiple measurements of individual iodine uptake for kinetics estimation may be unnecessary, and a population-based value can be used instead. Patients with renal impairment had similar outcome as other patients, but with a higher risk of dubious uptake measurements.

Contemporary Multimodality Imaging of Primary Hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is a disorder characterized by hypercalcemia and an elevated or inappropriately normal parathyroid hormone level. Classic features include bone pain, fractures, renal impairment, nephrolithiasis, and mental disturbance. However, most cases of PHPT are now asymptomatic at diagnosis or associated with nonspecific neurocognitive changes. The most frequent cause of PHPT is a solitary adenoma that secretes parathyroid hormone without the normal suppressive effect of serum calcium. A smaller number of cases can be attributed to multigland disease. Parathyroidectomy is curative and is considered for nearly all affected patients. Although PHPT is primarily a clinical and biochemical diagnosis, imaging is key to the localization of adenomas, which can lie in conventional locations adjacent to the thyroid gland or less commonly at ectopic sites in the neck and mediastinum. In addition, accurate localization facilitates the use of a minimally invasive or targeted surgical approach. Frequently used localization techniques include US, parathyroid scintigraphy, and four-dimensional CT. Second- and third-line modalities such as MRI, PET/CT, and selective venous sampling with or without parathyroid arteriography can increase confidence before surgery. These localization techniques, along with the associated technical aspects, relative advantages, and drawbacks, are described. Local expertise, patient factors, and surgeon preference are important considerations when determining the type and sequence of investigation. A multimodality approach is ultimately desirable, particularly in challenging scenarios such as multigland disease, localization of ectopic adenomas, and persistent or recurrent PHPT. Online supplemental material is available for this article. ©RSNA, 2022.

Shifting from open to video-assisted parathyroidectomy: effect of the adjustment period on safety, clinical outcomes and cost.

Bilateral neck exploration (BNE) has been the gold standard for the treatment of primary hyperparathyroidism (PHPT). Minimally invasive parathyroidectomy (MIP) has emerged as an alternative procedure for localised solitary adenomas. The most popular MIP techniques are the open MIP (OMIP) and the minimally invasive video-assisted parathyroidectomy (MIVAP). This study aims to assess whether we achieved a smooth transition from OMIP to MIVAP without compromising the results or increasing the cost. A parathyroid adenoma was successfully localised preoperatively in 77/86 patients with PHPT. MIP was contraindicated in 27/86 cases. For MIVAP, a 5mm, 30 degree camera was employed, along with special instruments. Median preoperative parathyroid hormone (PTH) level was 145.9pg/dl (59-2,151) and median calcium (Ca) was 10.8mg/dl (9.3-19). Comparing MIVAP (N=31) with OMIP (N=28), there was no significant difference in the age, sex, location of the adenoma, preoperative PTH and Ca levels as well as in all the other factors compared, apart from the size of adenomas, which were bigger in the OMIP group (1.85cm vs 1.4cm, p=0.032). Moreover, cure rates, operating time, hospital stay and rates of postoperative normocalcaemia were similar between the two groups. Despite the learning curve, MIVAP was not found to be inferior to OMIP for localised adenomas. The final cost was no higher for MIVAP than OMIP with the use of common reusable instruments. This, along with surgeons' experience in parathyroid and endoscopic surgery facilitates a smooth and cost-effective transition from OMIP to MIVAP.

IS CONFIRMATION OF PARATHYROID TISSUE BY FROZEN SECTION SUPERIOR TO LOCALIZATION OF SOLITARY PARATHYROID ADENOMA USING INTRAOPERATIVE GAMMA PROBE SURVEY? A RETROSPECTIVE COHORT STUDY.

In the surgical treatment of primary hyperparathyroidism, intraoperative localization of the diseased glands is an essential issue. We aimed to evaluate the impact of the intraoperative frozen section during radio-guided focused parathyroidectomy and compare its efficiency with intraoperative gamma probe survey and measurement of intraoperative quick parathyroid hormone. All consecutive patients underwent radio-guided focused parathyroidectomy for primary hyperparathyroidism due to solitary parathyroid adenoma. The outcomes of parathyroidectomy were evaluated by serum levels of calcium and parathyroid hormone. The primary outcome was the surgical cure diagnosed by normal serum calcium levels in the sixth postoperative month. A total of 55 patients with a mean age of 54.3±12.2 years were evaluated. The diagnostic accuracy of the preoperative localization tests was calculated as 92.7%. The intraoperative gamma probe survey impacted the operative plans of four patients (7.3%) by localizing the diseased gland in other positions. The accuracy of intraoperative quick parathyroid hormone and frozen section analysis was 100% for both. In all patients, serum calcium and PTH levels dropped to normal in the sixth postoperative month. There were no cases of the persistent or recurrent disease during the follow-up period. The results of the intraoperative gamma probe survey, intraoperative quick parathyroid hormone, and frozen section were concordant with the final pathology in all cases. In four patients (7.3%), intraoperative gamma probe survey impacted the operative plans. The intraoperative gamma probe survey may be used as the sole intraoperative method to locate the correct position of the solitary parathyroid adenoma.

Primary hyperparathyroidism: Correlation between cervical ultrasound and MIBI scan.

Introduction:The standard gold treatment of primary hyperparathyroidism (PHP) is parathyroidectomy. Imaging in particular, cervical ultrasound (US) and technetium-99 m- méthoxyisobutylisonitrileparathyroid scintigraphy using the single-photon emission computed tomography (TC-99 m-MIBI-SPECT) are always indicated prior to parathyroid surgery, allowing the location of parathyroid adenomas. The objective of our study is to evaluate the contribution of TC-99 m-MIBI-SPECT and US in the preoperative topographic diagnosis of PHP.Materials and Methods:this is a descriptive and analytical retrospective study, conducted in our department of Endocrinology, Diabetology and Metabolic Diseases in Hassan II University Hospital of Fez between 2009 and 2018. All patients who received a para-thyroidectomy for PHP were recruited. All patients had received a cervical US and a TC-99 m-MIBI-SPECT. We compared imaging data before surgery with data from intraoperative exploration and anatomopathological findings of surgical samples.Results:Forty-eight patients were collected. US correctly identified parathyroid adenoma in 85.40% of patients with PHP versus 89.50% in TC-99 m-MIBI-SPECT. US correctly predicted surgical outecomes in 97.60% of patients and TC-99 m-MIBI-SPECT in 97.72% of cases. Their combination had better results in sensitivity and positive predictive value.Conclusion:TC-99 m-MIBI-parathyroid scintigraphy SPECT had a higher probability for solitary parathyroid adenoma compared to cervical US. Its use coupled with the TC-99 m-MIBI-parathyroid scintigraphy SPECT allows reliable preoperative tracking.

Consideration of primary hyperparathyroidism in primary care

A sixty-seven-year-old female patient presented with symptomatic hypercalcemia as the first manifestation of primary hyperparathyroidism due to parathyroid adenoma. Initially the chronic hypercalcemia was investigated and then subsequent parathyroidectomy was done. She is doing very well six months following the surgery and the hypercalcemia has resolved completely. Asymptomatic hypercalcaemia due to primary hyperparathyroidism is a common condition in primary care1. Most commonly primary hyperparathyroidism is caused by a solitary parathyroid adenoma (80%), and less frequently multi-glandular adenoma, parathyroid hyperplasia or carcinoma2. Patients rarely present with symptomatic hypercalcemia (mnemonic “stones,” “bones,” “abdominal moans,” and “psychic groans”) whereas usually patients remain asymptomatic and the condition is discovered during routine checkup investigations3. The disorder can occur at any age, yet is more common in the middle age group (≥50 years). The ratio of such cases is equivalent to 1:1000 in males, whereas it is 3:1000 in the female population4.

AACE2021-A-1082: Primary Hyperparathyroidism: A Case Report of Management with Extra Ordinary Low Dose of Cinacalcet in an Elderly Male

Primary Hyperparathyroidism is a common cause of Hypercalcemia and is often seen in endocrine clinics. Majority of patients are found to have solitary parathyroid adenomas which may be associated with other endocrine problems. Common systemic complications are secondary osteoporosis, renal stones, pancreatitis and peptic ulcers. Surgery remains the mainstay of treatment for correction of pathology, however patients who do not meet the criteria or in whom surgery is contraindicated are managed conservatively and with calcimimetic agents such as cinacalcet. Case report and literature review. We are reporting a case of a 73 years old male who was referred to the endocrine clinic for work up of hypercalcemia. His past medical history was significant for well controlled Type 2 Diabetes and Hypertension. During his work up, he was found to have elevated serum calcium of 11.7 mg/dl, elevated serum PTH of 767 ng/L and 24 hours urinary calcium excretion of 446 mg/dl. Renal functions and 25 hydroxy vitamin D levels were within normal limits and the ultrasound and DEXA scan were negative for presence of any renal stone or osteoporosis. His two elder brothers also had a history of parathyroidectomy. He was reluctant for surgery and therefore imaging for the neck was also omitted. He was started on cinacalcet 15 mg/ day with an initial presumption of increase in dose requirement afterwards. However his serum calcium levels showed a remarked improvement and within one month they dropped to 9.9 mg/dl. The second subsequent test showed a serum calcium of 8.9 mg/dl after which the dose was reduced to 15 mg every alternate day. A presumption of tumor necrosis was made but the calcium levels rose higher on stopping cinacalcet and again went back to normal on the extra ordinary low dose of 15 mg every alternate day. His 3 years follow up to our clinic on this maintenance dose has shown steady calcium levels, improvements in serum PTH with fluctuations between 260 – 380 ng/L and no subsequent complication. Primary Hyperparathyrodism is a common cause of hypercalcemia which if left untreated can have serious systemic complications. Surgery remains the mainstay of treatment but in patients not meeting the criteria or in whom surgery is contraindicated, medical therapy is an option which includes dietary measures, bisphosphonates and calcimimetics like cinacalcet. The usual dose of cinacalcet is between 30 – 90 mg/day. Our case represents an unusual story of improvement on a very low dose of calcimimetic. More cases need to be evaluated and tested on low dose and may-be we can have a change in the recommendations in future.