Secondary and Tertiary Hyperparathyroidism among Patients with X-Linked Hypophosphatemia: A Systematic Review and Meta-analysis.

Secondary and tertiary hyperparathyroidism (SHPT and THPT) are frequent complications of chronic kidney disease and kidney transplantation, often impairing quality of life (QoL) through bone pain, fatigue, and pruritus. Parathyroidectomy is the definitive treatment for refractory cases, yet its impact on patient-reported QoL outcomes remains uncertain. We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines (PROSPERO CRD42025108038). Nine studies (n=675) with validated QoL assessments and ≥6months of follow-up were included. QoL was measured using SF-36, KDQOL, and Pasieka's parathyroid assessment of symptoms (PAS). Standardized mean differences (SMDs) were calculated, with analyses of physical (PCS) and mental (MCS) component summary scores. Meta-regression evaluated preoperative parathyroid hormone (PTH), calcium, and phosphorus as predictors of QoL change. Parathyroidectomy significantly improved global QoL (Hedges' g=1.05; 95% CI: 0.42-1.69; p=0.0011), PCS (SMD=0.85; 95% CI: 0.32-1.37; p<0.001), and MCS (SMD=0.40; 95% CI: 0.11-0.69; p=0.001). PAS scores also improved (SMD=-1.66; 95% CI: -2.72 to -0.60; p=0.004). Preoperative PTH, calcium, and phosphorus were not associated with postoperative QoL gains (p=0.71, 0.54, 0.47). Both subtotal and total parathyroidectomy provided comparable benefits (p=0.76). Parathyroidectomy leads to meaningful QoL improvements in CKD-related hyperparathyroidism, regardless of surgical technique. Baseline biochemical markers do not predict postoperative gains. Standardized, long-term studies of patient-reported outcomes are needed to guide surgical decision-making.

X-linked hypophosphatemia (XLH) is a chronic disabling hereditary musculoskeletal disorder associated with inactivating PHEX mutations and elevated circulating FGF-23 concentrations. In a placebo-controlled trial of adults with XLH, burosumab (anti-FGF-23 antibody) demonstrated durable improvements in phosphate concentrations, and self-reported stiffness and physical limitation. However, real-world data regarding burosumab efficacy and tolerability in adults with XLH are lacking. A retrospective audit was performed of patients (age ≥18-years) who commenced 4-weekly subcutaneous burosumab for XLH at Royal North Shore and Westmead Hospitals, Sydney, between January 2021 and June 2024. Patients were managed per standard clinical care and burosumab dose adjusted as necessary according to manufacturer instructions. Electronic medical records were reviewed to collate data regarding patient demographics, XLH-related complications and prior treatment, burosumab dosage and side effects, and pre- and post-burosumab biochemistry and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores. Of the 13 adults with XLH, all had hypophosphatemia before commencing burosumab (mean 0.64 ± 0.08 mmol/L). Mean WOMAC scores demonstrated baseline impairments in stiffness, pain, and physical limitation. Burosumab was administered for median 15 months during follow-up (median dose 70 mg). Hypophosphatemia resolved in all patients within 3 months of burosumab (mean 1.03 ± 0.38 mmol/L). Two patients developed hyperphosphatemia 2 weeks after commencing burosumab requiring dose reduction. One patient ceased burosumab in the setting of hypercalcemia and constipation secondary to pre-existing tertiary hyperparathyroidism. Adverse events were mild, including transient musculoskeletal discomfort (n = 4), restless legs (n = 2), injection site reaction (n = 2), and headache (n = 1). Repeat WOMAC within 12 months of commencing burosumab (n = 9) demonstrated clinically meaningful improvements in stiffness (-33.3 ± 12.5, p<.001) and physical function (−14.3 ± 16.2, p=.029). This study reports real-world outcomes of adults with XLH treated with burosumab. Clinical experience from 2 centers in Sydney supports trial findings that burosumab is well-tolerated and associated with improved serum phosphate concentrations and self-reported stiffness and physical function.

Information on tertiary hyperparathyroidism (THPTH) among chronic kidney disease (CKD) patients on haemodialysis in developing countries such as India is limited, and the mortality among them remains a query. This was a prospective cohort study conducted in at a tertiary care centre from June 2017 to June 2022. The index of suspicion for tertiary hyperparathyroidism was when investigations revealed high serum calcium and high alkaline phosphatase along with new onset of body aches, joint pains, and difficulty in walking. Patients, with above clinical features, were considered for 99m Tc-Sestamibi scan and high-resolution ultrasound of the neck, when serum parathormone was > 600pg/mL. Those patients diagnosed with tertiary hyperparathyroidism were followed up for 5years. The incidence of tertiary hyperparathyroidism among CKD patients was 13.4%. The mean age of CKD stage 5 patients with tertiary hyperparathyroidism was 55.17 ± 11.1years. The observation from our study was the mean survival time among patients who underwent parathyroidectomy and among patients who received cinacalcet was almost similar, whereas the mean survival time among patients who received phosphate binders was lower. However, the survival rate among patients on cinacalcet and who underwent parathyroidectomy were not statistically significant. There were no cross-sectional studies on prevalence of tertiary hyperparathyroidism in India as per our knowledge, although the prospective design, large sample size, PTH stratification, and frequent measurements of a comprehensive panel of mineral metabolites are strengths of the current study.

Objective: This study aimed to determine the incidence of tertiary hyperparathyroidism (THPT) among chronic kidney disease (CKD) patients on long-term hemodialysis in Swat, Pakistan, and identify key risk factors and complications. Study Design: Cross-sectional study. Setting: Miangul Abdul Haq Jahanzeb Kidney Teaching Hospital, Manglor Swat. Period: Jan and Feb 2025. Methods: A total of 200 adult hemodialysis patients (≥5 years) were screened. THPT was diagnosed based on persistently elevated parathyroid hormone (PTH) levels (&gt;300 pg/mL), hypercalcemia (&gt;10.5 mg/dL), and phosphate imbalance. Statistical analysis included independent t-tests, Chi-square tests, and binary logistic regression. Results: The incidence of THPT was 36% (n=72). Significant predictors included dialysis duration &gt;10 years (OR: 2.67; p&lt;0.001), PTH &gt;300 pg/mL (OR: 3.21; p&lt;0.001), hypercalcemia (OR: 2.89; p&lt;0.001), and lack of vitamin D therapy (OR: 1.98; p=0.002). THPT patients exhibited higher rates of vascular calcifications (48% vs. 22%), fractures (12% vs. 3%), and gastrointestinal complications (18% vs. 7%) (p&lt;0.05). Conclusion: The high burden of THPT (36%) among hemodialysis patients highlights the need for early screening, vitamin D supplementation, phosphate control, and timely parathyroidectomy referrals to mitigate complications.

Intraoperative parathyroid hormone monitoring criteria in secondary and tertiary hyperparathyroidism: A systematic review.

Introduction. In clinical practice, it is important to apply a differentiated approach to selecting the treatment strategy for patients with hyperparathyroidism, depending on clinical manifestations and laboratory changes. Aim. To analyse clinical variants and approaches of surgical treatment of patients with hyperparathyroidism. Materials and methods. We conducted a retrospective analytical study of hyperparathyroidism cases in patients who underwent surgery at the Non-Profit Enterprise "Regional Clinical Hospital of the Ivano-Frankivsk Regional Council" during 2019–2024. Clinical and laboratory characteristics and surgical approaches were studied. For statistical processing, STATISTICA 12 (StatSoft Inc., USA), Microsoft Excel, and variance-statistical analysis were used. Numerical data are presented as arithmetic mean (M), standard deviation (SD), and number of observations (n). Differences were assessed using Student's t-test; statistical significance was set at p &lt; 0.05. Results. A total of 77 surgeries were analysed: 67 for primary and 10 for tertiary hyperparathyroidism. In 62 patients (95.40%) with primary hyperparathyroidism, a solid adenoma was found, mostly in the lower parathyroid glands (85.07%). Most adenomas were diagnosed incidentally during thyroid ultrasound, predominantly in women (83.6%). The hypercalcaemic variant of primary hyperparathyroidism was detected in 56 patients (83.58%), while normal calcium levels were found in 11 (16.42%). There was insufficient evidence to confirm the normocalcaemic variant based on diagnostic criteria. Patients with primary hyperparathyroidism underwent selective parathyroidectomy; those with tertiary – subtotal parathyroidectomy. In all cases, the diagnosis was confirmed histologically. Conclusions. Most operated patients had the hypercalcaemic variant of primary hyperparathyroidism. Normocalcaemic variant cases require documented confirmation: stable normocalcaemia, elevated parathyroid hormone, and exclusion of causes of secondary hyperparathyroidism. Hyperparathyroidism treatment requires a personalized approach, considering type, variant, complications, and surgical indications.

Tertiary hyperparathyroidism in X linked hypophosphatemia: challenges and emerging therapeutic strategies

The diagnosis of a non-metastatic parathyroid carcinoma requires the demonstration of invasive growth that defines malignancy. These include angioinvasion or vascular invasion (i.e., tumor penetrating the vessel wall and associated with thrombus or intravascular tumor cells intermixed with thrombus), lymphatic invasion, perineural (intraneural) invasion, and/or direct invasion into adjacent anatomical structures. However, the distinction of a pT1 disease (8th edition of UICC TNM staging system) which represents a localized disease (tumor confined to the parathyroid gland or showing minimal extra-parathyroidal soft tissue invasion without direct invasion into adjacent structures) often requires meticulous microscopic examination that couples multiple levels and biomarker studies. Although the diagnostic criteria of malignancy are clearly defined, the identification of harbingers of invasive growth and distinguishing them from their mimics can pose diagnostic challenges. Several artifacts and manipulations can simulate malignancy. For example, a prior biopsy, PTH washout, ethanol injection, or any form of surgical manipulation may result in fibrosis, crush (mechanical) artifacts, or tissue distortion, which can obscure histological details and mimic invasion. Peliosis-the presence of extravasated erythrocytes without an endothelial lining-may simulate vascular invasion. Other common mimics include mechanically displaced intravascular tumor cells unassociated with thrombus, which can occur at the time of specimen handling. Extension of the tumor into the adjacent irregular connective tissue or pseudo-capsule can be mistaken for invasive growth. Similarly, an intrathyroidal location of the parathyroid gland adds another layer of complexity. In such cases, the boundary between the parathyroid tissue and surrounding thyroid parenchyma may not be clearly discernible, making it difficult to determine whether there is genuine invasive growth into thyroid (pT2 disease, 8th edition of UICC TNM system) or simply anatomical proximity. In addition, parathyromatosis and contour irregularities associated with long-standing secondary or tertiary hyperparathyroidism are other challenging manifestations. Atypical parathyroid tumors (WHO 2022) should also be clearly delineated using appropriate criteria. In summary, pathologists must be aware of the potential pitfalls that may lead to overdiagnosis of parathyroid carcinoma. A consolidated diagnostic workup, which combines multiple levels and biomarkers, is necessary to ensure diagnostic accuracy in all parathyroid tumors. This review provides practical insights on these diagnostic difficulties, illustrating common artifacts and mimics. We also discuss the relevant clinical, histological, immunohistochemical, and molecular features associated with parathyroid carcinoma, with the goal of enhancing diagnostic accuracy.

Letter to the editor "Tertiary hyperparathyroidism" in kidney transplant recipients: a misnomer?

Tertiary hyperparathyroidism (tHPT) is a common complication in kidney transplant (KT) recipients, often persisting despite successful graft function. However, the optimal treatment for improving long-term graft survival remains unclear. Parathyroidectomy (PTX) offers a definitive approach to restoring calcium homeostasis. This study aims to assess the effect of parathyroidectomy on graft failure, the need for dialysis, and renal osteodystrophy in the two groups. A retrospective analysis of electronic medical records from a multi-institutional database (TriNetX) was completed. Patients diagnosed with tHPT after KT were divided into two groups based on the type of intervention: cinacalcet or PTX. Patients were followed for up to 5 years, starting from the day after initiating cinacalcet or PTX. Propensity score matching (PSM) was used to balance demographics, comorbidities, creatinine levels before intervention, and vitamin D deficiency. Cox regression analysis was performed to determine measures of association. 811 patients were included in each treatment group after PSM. During the study period, 42.8% (n=347/811) of patients receiving Cinacalcet became dialysis-dependent, compared to 30.9% (n=251/811) of those who underwent surgery (p<0.01). Regarding renal osteodystrophy, 10.8% (n=74/684) of patients on cinacalcet developed the condition, while only 5.1% (n=32/628) in the PTX group experienced it (p<0.01). Additionally, 17.2% of those on cinacalcet experienced graft failure, compared to 12.6% in the PTX group (p<0.04). Patients who underwent parathyroidectomy experienced lower rates of kidney transplant failure and dialysis, outperforming Cinacalcet, a finding that should be cautiously interpreted regarding its clinical relevance. Improved electrolyte balance and PTH levels may be associated with a lower rate of renal osteodystrophy.

Hyperparathyroidism is a prevalent endocrine disorder that frequently manifests with severe symptoms. Primary hyperparathyroidism is caused by parathyroid adenoma, whereas secondary and tertiary hyperparathyroidism are typically reported in patients with renal failure on maintenance hemodialysis. Modern cinacalcet-based therapy for secondary hyperparathyroidism has long-term positive effects. However, surgical resection of affected parathyroid glands remains the only curative therapy option in tertiary hyperparathyroidism. In polyglandular primary and (especially) tertiary hyperparathyroidism, parathyroidectomy requires the most accurate examination of the parathyroid glands, thyroid gland, and surrounding structures. Despite advancements in preoperative topical and functional diagnostic approaches, the specific location of the affected parathyroid glands remains unknown until surgery in half of patients. Existing parathyroid imaging techniques, such as intraoperative ultrasound, gamma detection, and methylene blue staining, have demonstrated limited efficacy. Fluorescence imaging using indocyanine green, aminolevulinic acid, and various autofluorescence modes is highly effective. However, its use is limited by high equipment costs, reproducibility issues, and difficulties in achieving the claimed results. This necessitates improvements of intraoperative parathyroid imaging algorithms, which is the focus of this review.

Disclosure: R. Hilder: None. E. Berg: None. J. Weinreb: None.Background: Renal osteodystrophy is defined as abnormal bone histology and noted to be one component of metabolic bone disease associated with chronic kidney disease (CKD-MBD). It can be challenging to manage, and this challenge may be even greater post renal transplant due to the development of tertiary hyperparathyroidism (HPT). Here we report a case of severe tertiary HPT with osteitis fibrosa cystica and vitamin D deficiency. Clinical Case: A 29-year-old man with ESRD now 8 months post deceased donor renal transplant was evaluated for right hip pain. Labs showed calcium 8.4 mg/dL (reference range 8.6-10.4 mg/dL), phosphorus 3.1 mg/dL (2.3-4.4 mg/dL), albumin 4.4 mg/dL (3.9-5.0 mg/dL), Parathyroid hormone (PTH) 1223 pg/mL (11-51 pg/mL) creatinine 1.46 mg/dL from baseline 1.1mg/dL (0.6-1.3 mg/dL), ALP 952 U/L (37-113 U/L) and 25-hydroxy vitamin D 9 ng/mL (20-50 ng/mL). MRI revealed a multiloculated lesion in the right iliac bone and pubic ramus fracture. Biopsy showed lamellar and woven bone, fibrous tissue, and hemosiderin consistent with a brown tumor. Thyroid ultrasound revealed a 17 mm hypoechoic nodule consistent with a parathyroid adenoma. He was diagnosed with tertiary HPT, right iliac osteitis fibrosa cystica, and vitamin D deficiency-related osteomalacia.Notably, immediately following transplantation, PTH was >1700 pg/mL, prompting initiation of cinacalcet. Despite titration of cinacalcet, PTH remained markedly elevated and ergocalciferol 1250 mcg weekly was initiated, with resultant high normal serum calcium. Definitive treatment required referral for parathyroidectomy given severe tertiary HPT and osteitis fibrosa cystica. Conclusion: This case highlights an uncommon bone pathology, osteitis fibrosa cystica, as well as therapeutic challenges in the management of CKD-MBD with persistently elevated PTH. Although cinacalcet may lower PTH and improve calcium-phosphorus balance, nodular parathyroid glands do not involute. This is in part due to the downregulation of calcium sensing receptors and vitamin D receptors on these cells, and the high PTH with hypercalcemia often persists post-transplant. Persistent PTH elevation 6 months after transplantation is consistent with tertiary HPT. Hypovitaminosis D likely masked hypercalcemia in this case; thus, ergocalciferol was initiated cautiously, and calcium was monitored as it rose to the high normal range. Surgical intervention is usually deferred for 6-12 months post-transplantation while hormonal and electrolyte levels re-equilibrate, but parathyroidectomy remains the recommended treatment for persistent tertiary HPT refractory to medical therapy. This has been associated with marked improvement in bone mineral density and improvement in progression of brown tumors.Presentation: Monday, July 14, 2025

Disclosure: P. Pile: None. J. Arunachalam: None. P. Madhavan: None.Background: Previous studies have suggested an increased risk of malignancy in patients with primary hyperparathyroidism (PHPT), with one notable association being breast cancer, as highlighted in a 2007 Swedish study by Nilsson et al. Breast cancer is frequently linked to hypercalcemia of malignancy, which is often a sign of skeletal metastases. However, there is limited information on hypercalcemia in patients with breast cancer unrelated to skeletal metastases. Here, we present a retrospective, single institution study evaluating the prevalence of primary hyperparathyroidism in breast cancer. Methods: After receiving exemption from the institutional review board, we conducted a review of electronic medical records from our institution to assess the prevalence of hyperparathyroidism in breast cancer patients between July 2018 to December 2024. We used diagnosis codes for breast cancer and hyperparathyroidism to identify relevant patients. The study population consisted of all patients diagnosed with hyperparathyroidism (HPT), excluding those with chronic kidney disease (CKD), as these individuals might have secondary or tertiary hyperparathyroidism. Specifically, patients with CKD stages 3a, 3b, 4, and 5 were excluded from the analysis. Data collection was performed using Slicer Dicer in Epic, and descriptive statistics were applied to determine the proportion of patients with Vitamin D deficiency and bone metastases in patients with HPT and breast cancer, and prevalence of HPT. To compare prevalence rates, a Chi-square test was used. Results: The study identified 72 female breast cancer patients, aged 73 ± 10 years, who were diagnosed with HPT but did not have CKD. The prevalence of HPT in this group was found to be 2.12% (n=72), which is significantly higher than the prevalence of HPT in general population of 0.11% (n=1862), with a p-value < 0.001. Only 5 patients (0.07%) had distant bone metastases. Only 3 (0.04%) patients had Vitamin D deficiency (25-OH-D <20 ng/mL) at the time of elevated parathyroid hormone (PTH) levels, further supporting that elevated PTH was likely due to PHPT rather than secondary causes. Conclusion: This study reveals a significantly higher prevalence of PHPT in the breast cancer population compared to the general population. This study underscores the importance of evaluating PTH in patients with breast cancer and hypercalcemia even without the presence of bone metastases. Limitations of our study include the inclusion of males in the general population cohort, who have a lower prevalence of breast cancer. To address these limitations, we plan to further analyze patient characteristics in a future study to refine our findings and reduce such confounders.Presentation: Monday, July 14, 2025

Disclosure: C. Nguyen: None. M. Chiang: None. G.I. Uwaifo: None.Background; Diabetes Remission (DMR) is the metabolic state of restoration of normoglycemia with HBA1C < 5.7 without need of antidiabetic medications (ADM) in patients with known diabetes mellitus (DM). ESRD is associated with reduced ADM doses especially insulin and less commonly total resolution of ADM use with DMR. We present 3 patients with DMR in the setting of ESRD. Cases series; Case 1 is a 67 yr old man with type 2 diabetes (T2DM) of > 35 yr and strong family history. He has Hep C associated liver cirrhosis. He was initially managed with oral ADM then insulin only for the last 12yrs when he developed steadily declining renal function. He developed ESRD on dialysis in the preceding 7 yrs. At his prior contact with the endocrine consult service 4 yrs ago he had diabetic ketoacidosis (DKA) with HBA1C of 13. His DM is managed by his primary care provider (PCP) and at his next endocrine consult for hypocalcemia was noted to have been in DMR for prior 2 yrs with a current HBA1c of 4.9 on no ADM and BMI of 22.2kg/m2. CGMS profile confirmed normoglycemia. Case 2 is a 71 yr old man with T2DM of > 31 yr. He was initially managed with oral ADM and basal insulin eventually added. His 1st hospital admission with renal dysfunction was 3 yrs ago with an acute coronary syndrome and renal function rapidly declined from then to ESRD requiring dialysis with poorly controlled hypertension. Over the last 3 yrs he had all prior ADM discontinued and at his latest endocrine evaluation for evaluation of possible hypoglycemic episodes his HBA1c was 5.3 and BMI of 18 kg/m2. Case 3 is a 64 yr old man presumed T2DM of >24 yr initially started on oral ADM. He had multi dose insulin therapy added to his treatment ∼ 10 yrs ago on account of worsening glycemic control and by this time he had CKD stage 3b. Soon thereafter he progressed to ESRD on dialysis therapy. His T2DM was largely managed by his PCP and in the last 4 yrs had all ADM including insulin discontinued with nadir HBA1c of 4.7 and BMI of 26.5 kg/m2. He was recently re-evaluated by the endocrine service for possible tertiary hyperparathyroidism. Discussion; DMR in the setting of ESRD is a distinct entity but its exact prevalence, determinants and clinical consequences remain poorly understood and characterized. Our case series identified 3 caucasian men and common themes identified were the rapid onset of DMR following onset of ESRD (all <5 yrs from dialysis commencement) despite prior history of longstanding T2DM ( all >20 yrs). Also all our patients are normal to underweight with most having advanced micro and macrovacular disease. Conclusions; The entity of DMR in patients with DM and ESRD requires further study to help define the phenotype, predictors and clinical profile of patients that develop this and what implications it has for future cardiometabolic morbidity, mortality as well as hospital related admissions for typical DM related complications like DKA and hypoglycemia.Presentation: Saturday, July 12, 2025

Abstract Disclosure: J.E. Marquez: None. H.R. Go: None. M.A. Co: None. BackgroundWhile the treatment of Papillary Thyroid Cancer (PTC) by total thyroidectomy and some followed by radioactiveiodine (RAI) therapy is straightforward, use of RAI may pose a challenge in handling patients with coexisting End-Stage Renal disease (ESRD). Management challenges in treating PTC in a patient with ESRD may include the determination of ideal dosage of radioactive iodine and timing of hemodialysis to maximize its therapeutic effect while minimizing its radioactive side effects.Clinical CaseWe present a 44-year-old Filipino male with ESRD and tertiary hyperparathyroidism post total thyroidectomy with parathyroidectomy. Histopathology of the resected thyroid revealed multifocal PTC, a classical type on the right superior pole (1.2 cm) and infiltrative follicular variant on the left lobe (0.5 cm). There was no invasion of the lymphovascular space and extension beyond the thyroid, AJCC stage I (T1bN0M0). Radioactive iodine (RAI) ablation is not routinely recommended after total thyroidectomy for patients with ATA low risk DTC. However, specific clinical features such as multifocality (∼4-6%) made us decide to give radioactive iodine treatment to our patient. With collaborative discussion involving nephrology and nuclear medicine service, RAI dose 40 mCi was administered a month after surgery, radiation precautions were observed and discharged after 2 days with radiation activity &amp;lt;2mR/hr. Hemodialysis post RAI treatment was scheduled 48 hours post therapy. Differentiated Thyroid Cancer not only has higher incidence in Filipinos but also has higher disease recurrence and mortality rate compared with other ethnicities which warrants more aggressive management. End Stage Renal Disease prolongs the excretion of I131 which affects the radiation dose exposure to the body causing higher side effects particularly on the bone marrow. In dialysis patients, dosing recommendations were contradictory and the timing of hemodialysis is crucial. Existing literatures mostly suggest lowering 13-30% from the therapeutic dose. Dialysis is carefully planned to do hemodialysis pretreatment closest to administration of RAI and waiting 48 hours for the next treatment post-RAI treatment. Still, there is no specific recommendations in the use of RAI in patients with ESRD. ConclusionThis work reports our first experience in the use of RAI for managing thyroid cancer in a patient with ESRD undergoing hemodialysis. Only limited data, particularly in our local setting, is available given the rarity of thyroid cancer in hemodialysis patients. Multidisciplinary team approach involving specialists in nuclear medicine, endocrinology, and nephrology is of utmost importance in handling these subset of patients to facilitate the therapeutic benefits and safe use of RAI treatment. Presentation: Monday, July 14, 2025

Abstract Background and Aims Secondary and tertiary hyperparathyroidism are not infrequent in dialysis patients. Optimal medical management depends on both patients’ tolerance and side effects. This is usually limited by aberrant calcium and phosphorous levels or drug intolerance. Patients with adenomas are expected to need higher doses. Recently, microwave ablation (MWA) have shown promise as a minimally invasive treatment option for primary and secondary parathyroid nodules. This study, aimed to evaluate the effect of MWA of non-primary parathyroid nodules on patients’ PTH levels and the need for PTH suppressive therapy. Method This retrospective study included 46 patients on renal replacement therapy (RRT) (42; 91.3% on HD) who received thermal ablation therapy for the presence of parathyroid nodule(s) and followed in our center. We included patients reluctant to or not feasible for surgery and or intolerant to medical therapy. Those with malignancy, &amp;lt;18 years old, and who are not receiving RRT were excluded. Analysis of PTH was evaluated using the Roche Cobas e 801 analytical unit (Made in Germany). The intervention was performed by one experienced interventional radiologist using a 2.45-GHz microwave generator (MaxBlate, Canyon, China), and an 18-gauge water-cooled antenna was employed for the ablation under ultrasound guidance. Basal blood levels, as well as one hour post-procedure samples, were collected with the patients’ consent. Data analysis was performed by using SPSS-22 for Windows (Statistical Package for Social Science, SPSS Inc. Chicago IL, USA®Z). Results Out of the 46 cases, 33 (71.7%) had 1 adenoma, 10 (21.7%) had 2 adenomas, and 3 (6.5%) had 3 adenomas. The mean follow-up period was 8.7 ± 3.9 months. Four patients (8.7%) died during the follow-up period due to intervention unrelated causes. Due to the procedure, hoarseness developed in 2 patients (4.4%) and dysphagia in 1 patient (2.2%). All side effects resolved completely. The change in calcium levels after the procedure decreased significantly (Pre-post: Ca: 9.3 ± 0.8 mg/dL and Ca:9.0 ± 1.1 mg/dL, respectively, P = 0.033). The change between serum alkaline phosphatase (ALP) levels before and after the procedure is not significant [median (IQR) ALP = 257 (144–492) and median (IQR) ALP = 176 (105–546), respectively, P = 0.247]. The median of the decrease in PTH early after intervention was 41.8% (min:3,96%–max:85,6%). The change in PTH showed a decreasing trend with a persistent pattern over at least 6 months in majority of patients. Conclusion Microwave thermal ablation seems a good option as an alternative therapy to open surgery for parathyroid nodules secondary to CKD with comparable side effects and the advantage of being an outpatient procedure. Further studies are needed to guide the suitable timing and follow-up.

In Denmark, the parathyroidectomy rate due to primary hyperparathyroidism has increased over the last decade. Primary hyperparathyroidism leads to a range of diffuse neuromuscular symptoms, bone loss and kidney stones. Tertiary hyperparathyroidism can develop in secondary hyperparathyroidism from chronic renal failure. The predominant definitive treatment for both primary and tertiary hyperparathyroidism is surgery, generally preceded by localization imaging and usually with intraoperative parathyroid hormone assessment. This publication summarizes in this review the updated management of these diseases.

Patient: Female, 61-year-oldFinal Diagnosis: Extensive Mönckeberg sclerosis-like vascular calcification in the breast, associated with focal vascular occlusion, with secondary infarction and fat necrosisSymptoms: Painful palpable breast lumpClinical Procedure: Excision biopsy of breast • ultrasound-guided core needle breast biopsySpecialty: Pathology • Radiology • SurgeryObjective: Unusual clinical courseBackgroundBreast fat necrosis is a benign process in which fat undergoes aseptic saponification by blood and tissue lipase. It commonly occurs due to trauma or surgery and can mimic malignancy. We present an unusual case of atraumatic fat necrosis caused by extensive breast arterial calcifications in a woman with underlying diabetes mellitus and end-stage renal disease (ESRD).Case ReportA 61-year-old woman presented with a painful left breast lump for 3 days. Her medical history included hemodialysis-dependent ESRD, diabetic nephropathy, and poorly controlled tertiary hyperparathyroidism. Initial mammography revealed extensive arterial wall calcifications with no discrete mass, while ultrasound showed a poorly defined heterogeneous, predominantly hyperechoic mass. The lesion enlarged over 5 months, prompting surgical excision. Histopathological examination revealed extensive fat necrosis and widespread vascular calcification affecting variably sized vessels in a Mönckeberg sclerosis-like pattern. The calcification was severe enough to cause focal complete vascular occlusion with resultant infarction of breast fat.ConclusionsThis case highlights a rare and unusual presentation of atraumatic fat necrosis of the breast mimicking breast malignancy, both clinically and radiologically. Unlike the more common post-traumatic or post-surgical fat necrosis, this instance occurred in the absence of any known injury or intervention, making the diagnosis more challenging. It underscores the importance of considering fat necrosis in the differential diagnosis of breast masses in patients with ESRD, who often exhibit severe calcific vasculopathy, which can lead to tissue ischemia. Awareness of this potential mimic will be helpful in avoiding unnecessary interventions and guiding appropriate management.

Severe tertiary hyperparathyroidism as a rare mimicker of sacroiliitis