Total Parathyroidectomy Research Articles

Primary hyperparathyroidism in patients with multiple endocrine neoplasia type 1: Impact of genotype and surgical approach on long-term postoperative outcomes

BackgroundProtein-truncating germline pathogenic variants in the N- and C-terminal exons (2, 9, and 10) of the MEN1 gene may be associated with aggressive pancreatic neuroendocrine tumors. However, the impact of these variants on parathyroid disease is poorly understood. We sought to investigate the effects of genotype and surgical approach on clinical phenotype and postoperative outcomes in patients with multiple endocrine neoplasia type 1 (MEN1)-related primary hyperparathyroidism. MethodsWe identified patients with MEN1 evaluated at our institution from 1985 to 2020 and stratified them by genotype, (truncating variants in exons 2, 9, or 10, or other variants), and index surgical approach, (less-than-subtotal parathyroidectomy [<SPTX], SPTX, or total parathyroidectomy). We analyzed baseline characteristics, persistent/recurrent disease rates, and incidence of postoperative hypoparathyroidism. ResultsOf the 209 patients we identified, primary hyperparathyroidism was diagnosed in 194 (93%) and at a younger median age in those with truncating exon 2, 9, or 10 variants compared with other variants (27 years vs 31 years; P = .006). Median disease-free survival was significantly worse in patients who underwent <SPTX (60 months) than those who underwent <SPTX (152 months; P = .0005) or total parathyroidectomy (210 months; P = .04). Patients with truncating exon 2, 9, or 10 variants who underwent <SPTX had significantly shorter median disease-free survival than those with other variants (30 vs 84 months; P = .007). Prolonged hypoparathyroidism rates after final surgery were highest after total parathyroidectomy (40%), followed by <SPTX (9%) and SPTX (7%). ConclusionThe MEN1 genotype may affect the age of onset of primary hyperparathyroidism and the time to recurrence after surgery. <SPTX at index operation should be performed with caution, especially in patients with truncating MEN1 variants in exons 2, 9, or 10, as the higher risk of recurrence is not offset by a decreased incidence of permanent hypoparathyroidism compared to upfront SPTX.

SAT182 Effects Of An Orally Bioavailable Nonpeptide Parathyroid Hormone Receptor Type 1 (PTH1R) Antagonist In Rodent Models Of Primary Hyperparathyroidism (PHPT)

Abstract Disclosure: A.S. Antwan: Employee; Self; Crinetics Pharmaceuticals. E. Rico-Bautista: Employee; Self; Crinetics Pharmaceuticals. J. Pontillo: Employee; Self; Crinetics Pharmaceuticals. S. Wang: Employee; Self; Crinetics Pharmaceuticals. M. Johns: Employee; Self; Crinetics Pharmaceuticals. B. Ramms: Employee; Self; Crinetics Pharmaceuticals. M.A. Fowler: Employee; Self; Crinetics Pharmaceuticals. J.B. Nguyen: Employee; Self; Crinetics. A.A. Castellanos Gonzalez: Employee; Self; Crinetics. B. Fleck: Employee; Self; Crinetics Pharmaceuticals. K. Retting: Employee; Self; Crinetics Pharmaceuticals. D. Dalvie: Employee; Self; Crinetics Pharmaceuticals. S.F. Betz: Employee; Self; Crinetics Pharmaceuticals. S. Markison: Employee; Self; Crinetics Pharmaceuticals. Primary hyperparathyroidism (PHPT) is a condition resulting from an over-secretion of parathyroid hormone (PTH) from one or more overactive parathyroid glands. PTH is a peptide hormone that regulates blood calcium concentrations through effects on bone, intestines, and kidney. PTH acts on parathyroid hormone receptor type 1 (PTH1R) in the kidney to increase calcium reabsorption and block phosphate reabsorption. The loss of phosphate ions then causes an increase in ionized calcium in the blood and cAMP in the urine. At the bone, continuous PTH infusion stimulates osteoclast activity while inhibiting osteoblast activity, leading to breakdown of bone and release of calcium into the extracellular fluid. Conditions that cause excess PTH, such as PHPT, result in elevated concentrations of plasma calcium, increased bone loss, increased fracture risk, and higher susceptibility to kidney stone development. PHPT affects approximately 100,000 patients per year, but many patients are asymptomatic and remain undiagnosed. While a partial or total parathyroidectomy may be suitable for patients diagnosed with severe cases of PHPT, there are limited treatment options for those who do not meet the criteria or do not wish to undergo surgery. The goals for medicinal treatment are to normalize blood calcium levels and urinary calcium excretion, as well as increase bone mineral density to reduce fracture risk. Blocking PTH action directly via a potent PTH1R antagonist may provide an important new therapeutic mechanism to treat patients with PHPT. Using iterative medicinal chemistry and pharmacology, Crinetics has identified several potent and orally bioavailable PTH1R antagonists with good drug-like properties. Lead molecules were evaluated in vivo in preclinical rodent models for their ability to suppress the effects of excess PTH on serum calcium, bone turnover, and cAMP levels in the kidney. One of these compounds, ANT-5, was characterized as a potent negative allosteric modulator of both human and rat PTH1R. In rats, oral administration of ANT-5 dose-dependently suppressed PTH-induced hypercalcemia. ANT-5 also suppressed PTH-stimulated urinary cAMP in rats, indicating its ability to inhibit the actions of PTH in the kidney. We further evaluated the effect of ANT-5 in a rodent model of continuous PTH infusion-induced bone turnover. Once-daily oral administration of ANT-5 mitigated PTH-induced bone resorption, suggesting that inhibiting PTH1R may have beneficial clinical effects on bone density. The culmination of these studies has led to a subset of candidate molecules that are being evaluated in safety studies to identify the compound(s) suitable for evaluation in human clinical trials. Support: Crinetics Pharmaceuticals. Presentation: Saturday, June 17, 2023

Calciphylaxis in a patient with hypoparathyroidism and MEN-1 syndrome.

Calciphylaxis is a rare disorder characterised by the development of painful necrotic skin lesions. Occlusion of cutaneous arterioles due to ectopic calcification leads to potentially life-threatening widespread skin loss. Most cases occur in patients with chronic renal disease, which leads to dysregulation of calcium and phosphate homeostasis. Only a handful of case reports exist describing calciphylaxis occurring in patients without chronic renal disease but with hypoparathyroidism. We report on a unique case of a 53-year-old man with multiple endocrine neoplasia type 1 syndrome and acquired hypoparathyroidism due to total parathyroidectomy who went on to develop calciphylaxis following cardiac surgery. Calciphylaxis most commonly occurs in the context of chronic renal disease but can rarely occur in its absence as a consequence of calcium and phosphate dysregulation. Patients who develop necrotic skin lesions in the presence of hypoparathyroidism require an urgent dermatological opinion. Mortality from calciphylaxis is high, with the majority of deaths occurring secondary to sepsis. Management of calciphylaxis requires a multidisciplinary team approach to manage wound healing, infections and pain. Recovery with full rehabilitation from calciphylaxis can take months to years.

Hungry bone syndrome in peritoneal dialysis patients after parathyroid surgery.

Secondary hyperparathyroidism (SHPT) is a common complication of end-stage kidney disease (ESKD). Hungry bone syndrome (HBS) occurs frequently in patients on maintenance dialysis receiving parathyroidectomy for refractory SHPT. However, there is scanty study investigating the clinical risk factors that predict postoperative HBS, and its outcome in peritoneal dialysis (PD) patients. We conducted a single-center retrospective study to analyze 66 PD patients who had underwent parathyroidectomy for secondary hyperparathyroidism at Chang Gung Memorial Hospital between 2009 and 2019. The patients were stratified into two groups based on the presence (n=47) or absence (n=19) of HBS after parathyroidectomy. Subtotal parathyroidectomy was the most common surgery performed (74.2%), followed by total parathyroidectomy with autoimplantation (25.8%). Pathological examination of all surgical specimens revealed parathyroid hyperplasia (100%). Patients with HBS had lower levels of postoperative nadir corrected calcium, higher alkaline phosphate (ALP), and higher potassium levels compared with patients without HBS (all P<0.05). A multivariate logistic regression model confirmed that lower preoperative serum calcium level (OR 0.354, 95% CI 0.133-0.940, P=0.037), higher ALP (OR 1.026, 95% CI 1.008-1.044, P=0.004), and higher potassium level (OR 6.894, 95% CI 1.806-26.317, P=0.005) were associated with HBS after parathyroidectomy. Patients were followed for 58.2±30.8 months after the surgery. There was no significant difference between HBS and non-HBS groups in persistence (P=0.496) or recurrence (P=1.000) of hyperparathyroidism. The overall mortality rate was 10.6% with no significant difference found between both groups (P=0.099). We concluded that HBS is a common complication (71.2%) of parathyroidectomy for SHPT and should be managed appropriately.

SP4.2 Saving inpatient beds: Are day-case total parathyroidectomies possible and safe?

Abstract Introduction Total parathyroidectomy on patients with hyperparathyroidism traditionally required an inpatient hospital stay to monitor patients for postoperative hypocalcaemia. Our centre developed a safe protocol in 2015 which enables total parathyroidectomies to be carried out as a day-case procedure. This protocol, developed in conjunction with the renal physicians, involves giving the patient oral alfacalcidol preoperatively for 5 days and close monitoring of the calcium levels postoperatively to permit safe same day discharge. Methods A single centre retrospective study was carried out on all patients who underwent a total parathyroidectomy for hyperparathyroidism between 2005 and 2022. A comparison study was done before and after the protocol was introduced in 2015. Data were collected regarding the patient comorbidities, peri-operative calcium level, post-operative calcium, potassium and parathyroid levels, length of hospital stay, operative procedure details, hospital readmission, and 30-day morbidity. Results 57 patients underwent total parathyroidectomy during the study period (22 before protocol and 35 after the protocol). After introduction of the protocol, 40% of patients were discharged on the same day, compared to only 4.54% previously. The duration of inpatient hospital stay was reduced from 0-13 days to 0-3 days. Reasons for prolonged hospital stay in the remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patient required readmission during the 30-day post-operative period. Conclusions Day-case surgery for total parathyroidectomy can be achieved safely in patients with a preoperative regimen of alfacalcidol and close monitoring of calcium levels post-operatively, emulating a virtual ward round.

SP4.3 Improving management of post operative hypocalcaemia in Total Thyroidectomy and Parathyroidectomy surgery

Abstract Aim Post-operative hypocalcaemia is a serious complication of thyroid and parathyroid surgery if not recognised and treated immediately. With sub specialisation and day case surgery, on call may be unfamiliar with immediate management. This can lead to non standardised and inefficient management of patients. The aim was to develop a patient information card which outlined the symptoms of hypocalcaemia and initial evidenced based management for the managing health care professional. Method For this quality improvement work a questionnaire was produced and provided to service users following Total Thyroidectomy and Parathyroidectomy surgery at a regional endocrine surgery unit. Data was collected post surgery before and after the intervention was introduced. Results A positive response to the introduction of a card with a QR code leading to management guidelines which is an evidence-based guide for professionals assessing patients with hypocalcaemia. Furthermore, patient confidence identifying symptoms of hypocalcaemia improved. Conclusion The introduction of a post-operative hypocalcaemia business sized card has standardised post operative triage and management of symptoms in a regional endocrine surgery service.

Comparing subtotal parathyroidectomy and total parathyroidectomy with autotransplantation in renal transplant recipients.

Both subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX + AT) are considered acceptable surgical approaches for renal patients. It is common that parathyroid surgery is performed in patients before they undergo kidney transplantation and there is currently no evidence considering the best surgical approach in this subset of patients. Two cohorts were identified of consecutive patients who underwent parathyroidectomy for renal hyperparathyroidism by two surgeons at a single institution over equivalent time periods (SPTX and TPTX + AT). A retrospective chart review was performed to assess these techniques, including outcomes following kidney transplantation. There were 125 patients analysed, with 56 patients who underwent SPTX and 69 who underwent TPTX + AT. Both cohorts effectively reduced PTH post operatively. There were 22 patients in the SPTX cohort and 26 in the TPTX + AT cohort that subsequently received kidney transplants. There were no cases of recurrent hyperparathyroidism and one of hypoparathyroidism (4.5%) in the SPTX patients post-transplant. There was one case of recurrent hyperparathyroidism (3.8%) and four of persistent hypoparathyroidism (15.4%) in the TPTX + AT patients post-transplant. Surgery for renal hyperparathyroidism requires a careful balance of the extent of parathyroid resection to prevent persistent/recurrent disease and avoid permanent hypoparathyroidism. SPTX may be a more appropriate option in kidney transplant candidates in order to minimise the risk of long-term hypoparathyroidism.

Perioperative nursing of a patient undergoing total parathyroidectomy with subcutaneous autotransplantation for secondary hyperparathyroidism

Perioperative nursing of a patient undergoing total parathyroidectomy with subcutaneous autotransplantation for secondary hyperparathyroidism

Successful treatment of severe calciphylaxis in a renal transplant patient with previous total parathyroidectomy.

Calciphylaxis is a rare dermatological condition strongly associated with chronic kidney disease. The clinical course can be devastating, with high associated morbidity and mortality. The pathophysiology and optimum treatment remain uncertain. Calciphylaxis is known mostly to affect dialysis patients but is less frequently reported in renal transplant recipients. We report the case of a renal transplant recipient who had undergone previous total parathyroidectomy. Diagnosis was made at the time of limb amputation, yet despite this relatively late diagnosis she made a good recovery. We believe this resulted from a multi-modal approach including surgical debridement, sodium thiosulphate and vitamin K2 therapy. She remained free from recurrence 2 years after completion of treatment, despite on-going vitamin D replacement. There is much still to ascertain regarding calciphylaxis treatment, including the optimal regimens and duration of therapy, particularly in the transplant recipient population where data are limited.

Chronic dialysis patient with severe secondary hyperparathyroidism undergoing parathyroidectomy in Indonesia: a case series

Link of Video Abstract: https://youtu.be/d196XKGsPekBackground: Parathyroidectomy is a method of treating secondary hyperparathyroidism associated with Chronic Kidney Disease (CKD), which has been largely abandoned in developed countries due to the existence of calcimimetic drugs which are reported to be effective in treating secondary hyperparathyroidism in this population. However, in developing countries like Indonesia, the availability of Calcimimetic drugs is still rare and expensive, so that parathyroidectomy can be an option. The study aimed to present four case reports of chronic HD patients with SHPT accompanied by clinical symptoms. As far as our knowledge goes, this is the first case series reported from Indonesia. Case Presentation: This research is a multicenter case series study. All patients had undergone dialysis for five years and complained of body aches. All calcium levels were within the normal range, while three patients had hyperphosphatemia and one patient had normal phosphate levels. All patients had iPTH levels &gt;1000 pg/ml in the last six months. Before the surgery, all patients had received long-term phosphate-binding drugs, including calcium-based and non-calcium-based drugs and vitamin D3 agonists. All patients underwent total parathyroidectomy with autotransplantation of parathyroid tissue in the right antebrachial regions, except for the second patient who received the transplant in the left antebrachial region due to an AV fistula in the right arm. Conclusion: In dialysis patients, especially in developing countries, approximately 10.7% of them experience SHPT with PTH levels &gt;1,000 pg/mL, and one study in Indonesia showed that around 35% of patients undergoing chronic hemodialysis had PTH levels &gt;200 pg/ml, making parathyroidectomy a highly possible option considering that medications such as cinacalcet are more expensive and not widely available.

Prevalence and current approaches to the treatment of secondary hyperparathyroidism and its complications in chronic kidney disease: a literature review

There is a universal trend towards increase of patients with chronic kidney disease by 7% on average. In the Russian Federation, the annual increase is even higher, at about 10%. The average age of patients receiving renal replacement therapy is 60 years in the Tomsk region and 56 years in Russia, which is relatively lower than in European countries and the United States. With increasing age of patients receiving dialysis treatment, a progressive increase in the incidence of secondary hyperparathyroidism is recorded. Mineral and bone disorders, hyperphosphatemia, hypercalcemia all lead to premature vascular calcification, increase the risk of cardiovascular complications and death. At the same time, elderly patients are characterized by an increase in risks immediately after the start of dialysis therapy. There is a global tendency towards increase in the target level of parathyroid hormone. Parathyroidectomy is recognized as a gold standard for treatment of drug-resistant hyperparathyroidism across the world. As the development of hyperplasia in the parathyroid glands does not proceed synchronously, instead progressing at different rates and in the selective glands, methods of local influence on the altered glands have recently been developed in order to gradually control secondary hyperparathyroidism. Alternative to the total parathyroidectomy are minimally invasive non-surgical methods, attractive due to a smaller number of complications, such as bleeding and paresis of the recurrent laryngeal nerve. Examples of minimally invasive methods are local injections of preparations of the active form of vitamin D, which lead to apoptosis of parathyroid gland cells instead of their destruction, and are safer in relation to surrounding tissues. This article presents current data on the prevalence of secondary hyperparathyroidism in chronic kidney disease. An analysis of clinical trials was carried out based on articles indexed in the Scopus database, the Russian Science Citation Index, PubMed and Web of Science.

Recurrence After Surgery for Primary Hyperparathyroidism in 517 Patients With Multiple Endocrine Neoplasia Type 1: An Association Francophone de Chirurgie Endocrinienne and Groupe d'étude des Tumeurs Endocrines study.

To assess recurrence according to the type of surgery for primary hyperparathyroidism (pHPT) in multiple endocrine neoplasia type 1 ( MEN1 ) patients and to identify the risk factors for recurrence after the initial surgery. In MEN1 patients, pHPT is multiglandular, and the optimal extent of initial parathyroid resection influences the risk of recurrence. MEN1 patients who underwent initial surgery for pHPT between 1990 and 2019 were included. Persistence and recurrence rates after less than subtotal parathyroidectomy (LTSP) and subtotal parathyroidectomy (STP) were analyzed. Patients with total parathyroidectomy with reimplantation were excluded. Five hundred seventeen patients underwent their first surgery for pHPT: 178 had LTSP (34.4%) and 339 STP (65.6%). The recurrence rate was significantly higher after LTSP (68.5%) than STP (45%) ( P < 0.001). The median time to recurrence after pHPT surgery was significantly shorter after LTSP than after STP: 4.25 (1.2-7.1) versus 7.2 (3.9-10.1) years ( P < 0.001). A mutation in exon 10 was an independent risk factor of recurrence after STP (odds ratio = 2.19; 95% CI: 1.31; 3.69; P = 0.003). The 5 and 10-year recurrent pHPT probabilities were significantly higher in patients after LTSP with a mutation in exon 10 (37% and 79% vs 30% and 61%; P = 0.016). Persistence, recurrence of pHPT, and reoperation rate are significantly lower after STP than LTSP in MEN1 patients. Genotype seems to be associated with the recurrence of pHPT. A mutation in exon 10 is an independent risk factor for recurrence after STP, and LTSP may not be recommended when exon 10 is mutated.

Robotic resection of ectopic mediastinal parathyroid adenoma in multiple endocrine neoplasia 1

BackgroundHyperparathyroidism in patients with multiple endocrine neoplasia 1 is attributed to the excessive secretion of parathyroid hormone (PTH) from multiple parathyroid glands. This can be successfully treated through complete resection of the parathyroid glands; however, subsequent surgery is often required because of the presence of supernumerary or ectopic parathyroid glands. Therefore, identifying the locations of all functional glands is crucial for precise resection. Here, we report a case of ectopic mediastinal parathyroid adenoma that was successfully resected using robot-assisted thoracoscopic surgery.Case presentationA 53-year-old woman underwent a total parathyroidectomy with autotransplantation for multiple endocrine neoplasia 1-associated primary hyperparathyroidism. The patient previously underwent laparoscopic distal pancreatectomy for a pancreatic neuroendocrine tumor. She also presented with a mediastinal tumor and nonfunctional pituitary adenoma that could be followed up. Blood tests before total parathyroidectomy showed high levels of intact PTH (183 pg/mL) and calcium (Ca; 10.3 mg/dL); however, postoperative blood tests still revealed high levels of intact PTH (103 pg/mL) and Ca (11.4 mg/dL). Computed tomography and magnetic resonance imaging revealed a 45-mm-sized mass in the right upper mediastinum as a well-defined solid and cystic lesion, whereas 99mTc-methoxyisobutylisonitrile scintigraphy indicated a strong accumulation of tracers, suggesting an ectopic lesion in the mediastinum. Persistent hyperparathyroidism after total parathyroidectomy via neck incision was attributed to an ectopic parathyroid tumor in the mediastinum. Thus, we decided to resect the tumor using robot-assisted thoracoscopic surgery to perform the procedure gently and carefully. During surgery, a mediastinal tumor was identified as it was detected radiographically. Because it did not invade the surrounding tissues, it could be completely resected without injuring the capsule. The patient was discharged without complications. Postoperatively, Ca and intact PTH levels decreased back to normal. The final pathological diagnosis confirmed that the mass was an ectopic mediastinal parathyroid adenoma.ConclusionsMinimally invasive surgical resection of a remnant ectopic lesion was successfully performed in a patient with multiple endocrine neoplasia 1 using robot-assisted thoracoscopic surgery.

Maximal parathyroid gland diameter as a predictive factor for autograft-dependent recurrent secondary hyperparathyroidism after total parathyroidectomy.

Following total parathyroidectomy (PTx), transcervical thymectomy, and forearm autograft for secondary hyperparathyroidism (SHPT), recurrent SHPT can occur in the autografted forearm. However, few studies have investigated the factors contributing to re-PTx due to autograft-dependent recurrent SHPT before the completion of the initial PTx. A total of 770 patients who had autografted parathyroid fragments derived from only one of the resected parathyroid glands (PTGs) and who had undergone successful initial total PTx and transcervical thymectomy-defined by serum intact parathyroid hormone level < 60 pg/mL on postoperative day 1-between January 2001 and December 2022 were included in this retrospective cohort study. Factors contributing to re-PTx due to graft-dependent recurrent SHPT before the completion of the initial PTx were investigated using multivariate Cox regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to obtain the optimal maximum diameter of PTG for autograft. Univariate analysis showed that dialysis vintage and maximum diameter and weight of the PTG for autograft were significant factors contributing to graft-dependent recurrent SHPT. However, multivariate analysis revealed that dialysis vintage (P=0.010; hazard ratio [HR], 0.995; 95% confidence interval [CI], 0.992-0.999) and the maximum diameter of the PTG for autograft (P=0.046; HR, 1.107; 95% CI, 1.002-1.224) significantly contributed to graft-dependent recurrent SHPT. ROC curve analysis showed that < 14mm was the optimal maximum diameter of PTG for autograft (area under the curve, 0.628; 95% CI, 0.551-0.705). The dialysis vintage and maximum diameter of PTG for autograft may contribute to re-PTx due to autograft-dependent recurrent SHPT, which can be prevented by using PTGs with a maximum diameter of < 14mm forautograft.

Retrosternal parathyromatosis in a patient with prior total parathyroidectomy

Abstract Parathyromatosis is a rare cause of recurrent primary hyperparathyroidism that often follows surgical removal of the parathyroid gland. Foci of parathyromatosis are most commonly found in the neck, mediastinum, and sites of autotransplantation. A 36-year-old male with renal failure and prior parathyroidectomy presented with generalized bone pain, for which laboratory investigations revealed hyperparathyroidism. Preoperative coil localization was utilized followed by thoracoscopy using fluoroscopy for resection of ectopic parathyroid tissue. The specimen was sent to histopathology, which revealed multiple nodules of hypercellular parathyroid tissue, consistent with the diagnosis of parathyromatosis. Parathyromatosis is a rare cause of recurrent hyperparathyroidism, with surgical removal being the only curative option. Follow-up is essential as it can commonly recur.

Prevalence and current approaches to the treatment of secondary hyperparathyroidism and its complications in chronic kidney disease: a literature review

There is a universal trend towards increase of patients with chronic kidney disease by 7% on average. In the Russian Federation, the annual increase is even higher, at about 10%. The average age of patients receiving renal replacement therapy is 60 years in the Tomsk region and 56 years in Russia, which is relatively lower than in European countries and the United States. With increasing age of patients receiving dialysis treatment, a progressive increase in the incidence of secondary hyperparathyroidism is recorded. Mineral and bone disorders, hyperphosphatemia, hypercalcemia all lead to premature vascular calcification, increase the risk of cardiovascular complications and death. At the same time, elderly patients are characterized by an increase in risks immediately after the start of dialysis therapy. There is a global tendency towards increase in the target level of parathyroid hormone. Parathyroidectomy is recognized as a gold standard for treatment of drug-resistant hyperparathyroidism across the world. As the development of hyperplasia in the parathyroid glands does not proceed synchronously, instead progressing at different rates and in the selective glands, methods of local influence on the altered glands have recently been developed in order to gradually control secondary hyperparathyroidism. Alternative to the total parathyroidectomy are minimally invasive non-surgical methods, attractive due to a smaller number of complications, such as bleeding and paresis of the recurrent laryngeal nerve. Examples of minimally invasive methods are local injections of preparations of the active form of vitamin D, which lead to apoptosis of parathyroid gland cells instead of their destruction, and are safer in relation to surrounding tissues. This article presents current data on the prevalence of secondary hyperparathyroidism in chronic kidney disease. An analysis of clinical trials was carried out based on articles indexed in the Scopus database, the Russian Science Citation Index, PubMed and Web of Science.

Pre-operative Cinacalcet Administration Reduces Immediate Post-operative Hypocalcemia Following Total Parathyroidectomy in Severe Renal Hyperparathyroidism.

In severe renal hyperparathyroidism (RHPT), whether administrating Cinacalcet before total parathyroidectomy can reduce post-operative hypocalcemia remains unclear. We compared post-operative calcium kinetics between those who took Cinacalcet before surgery (Group I) and those who did not (Group II). Patients with severe RHPT (defined by PTH ≥ 100pmol/L) who underwent total parathyroidectomy between 2012 and 2022 were analyzed. Standardized peri-operative protocol of calcium and vitamin D supplementation was followed. Blood tests were performed twice daily in the immediate post-operative period. Severe hypocalcemia was defined as serum albumin-adjusted calcium < 2.00mmol/L. Among 159 patients who underwent parathyroidectomy, 82 patients were eligible for analysis (Group I, n = 27; Group II, n = 55). Demographics and PTH levels before Cinacalcet administration were comparable (Group I: 169 ± 49pmol/L vs Group II: 154 ± 45, p = 0.209). Group I had significantly lower pre-operative PTH (77 ± 60pmol/L vs 154 ± 45, p < 0.001), higher post-operative calcium (p < 0.05), and lower rate of severe hypocalcemia (33.3% vs 60.0%, p = 0.023). Longer duration of Cinacalcet use correlated with higher post-operative calcium levels (p < 0.05). Cinacalcet use for > 1year resulted in fewer severe post-operative hypocalcemia than non-users (p = 0.022, OR 0.242, 95% CI 0.068-0.859). Higher pre-operative ALP independently correlated with severe post-operative hypocalcemia (OR 3.01, 95% CI 1.17-7.77, p = 0.022). In severe RHPT, Cinacalcet led to significant drop in pre-operative PTH, higher post-operative calcium levels, and less frequent severe hypocalcemia. Longer duration of Cinacalcet use correlated with higher post-operative calcium levels, and the use of Cinacalcet for > 1year reduced severe post-operative hypocalcemia.

Endoscopic total parathyroidectomy via anterior chest approach with forearm autotransplantation for secondary hyperparathyroidism: a comparison of surgical results with open total parathyroidectomy with autotransplantation.

This paper aimed to evaluate the clinical value of performing an endoscopic total parathyroidectomy through anterior chest approach with autotransplantation (EACtPTx+AT) in treating secondary hyperparathyroidism (SHPT) to summarize and share the clinical experience. 24 patients with SHPT were retrospectively analyzed:11 patients underwent open total parathyroidectomy with autotransplantation (OtPTx+AT Group) and 13 patients underwent endoscopic parathyroidectomy through anterior chest approach with autotransplantation (EACtPTx+AT Group). Comparing the two groups regarding the following factors: (1) operating conditions, such as the blood loss during the operation, the length of time spent on the operating table, the number of parathyroid glands removed, postoperative drainage volume and hospital stay. (2) clinical efficacy, parathyroid hormone (PTH) and serum calcium (Ca) levels. (3) postoperative complications. First, there were no significant differences in the number of parathyroid gland resection, operation time, intraoperative blood loss and hospital stay between the two groups. While there were significant differences in postoperative drainage volume between the two groups. Second, the two groups preoperative PTH and preoperative serum calcium decreased significantly compared with those of the two groups after surgery and there was a statistically significant difference. Thirdly, there was no postoperative bleeding, hoarseness or choking in the two groups and no conversion to open surgery case in EACtPTx+AT group. Endoscopic treatment of SHPT using the anterior chest approach with forearm autotransplantation significantly improves clinical symptoms and lowers levels of PTH and serum calcium after the operation. The results confirm the operation's safety and effectiveness.

Abstract #1409805: Parathyroid Carcinoma Camouflaging as Secondary Hyperparathyroidism- A Case Report

Parathyroid carcinoma is a rare endocrine tumor accounting for less than 1% of all hyperparathyroidism. Mostly it manifests as primary hyperparathyroidism. However, parathyroid carcinoma arising on the background of secondary hyperparathyroidism is unusual which if overlooked could increase the risk of morbidity and mortality. A 35-year-old gentleman diagnosed with end stage renal disease (ESRD) two years back on hemodialysis presented with bilateral fore feet pain for 5 months. Clinical examination was unremarkable except for pale conjunctiva. No neck mass was palpable. On workup he was diagnosed to have secondary hyperparathyroidism secondary to vitamin D3 deficiency resulting from CKD. He was being managed medically but despite that his PTH levels remained high 2399.1pg/ml. On further workup ultrasound neck showed hypoechoic, non-vascular lesion measuring 1.6 x 1.3cm outside the left lobe of thyroid gland and in between the left lobe of thyroid gland and carotid vessels, suggestive of enlarged parathyroid gland which was further supported by sestamibi scan. Hence, he underwent minimally invasive left parathyroidectomy and biopsy report revealed low grade parathyroid carcinoma measuring 2 x 1cm showing capsular, vascular and focal invasion into the adipose tissue and no perineural invasion. The Ki67 proliferative index was 5-7%. After surgery his symptoms persisted and PTH levels continued to rise. Sestamibi scan 6 months after parathyroidectomy revealed enlarged right upper parathyroid gland. His whole-body scan was negative for metastasis and the bone scan showed superscan suggestive of metabolic bone disease. He subsequently underwent enbloc resection of left side along with near total parathyroidectomy whose biopsy revealed right parathyroid adenoma. Elevated PTH levels in CKD is mostly attributed to secondary hyperparathyroidism. However, rare cases have been reported where parathyroid carcinoma was discovered in CKD patients with underlying secondary or tertiary hyperparathyroidism. CKD is one of the risk factors for cancer leading to 1.2 to 1.5-fold increased cancer risk. ESRD in our patient might have led to the development of parathyroid carcinoma. Parathyroid carcinoma are usually hyperfunctioning and symptomatic like this case and less than 10% are asymptomatic and non-functional. 30-75% of cases present as a neck lump which was not found in this case. Distinguishing between parathyroid adenoma versus carcinoma is crucial as the extent of surgical resection depends on it. Though histopathology of excised tumor helps in diagnosing malignancy but at times it confronts with diagnostic challenges. Presence of one of the features such as vascular invasion, perineural invasion, adjacent structure invasion and metastasis strongly suggest parathyroid malignancy some of which were seen in our case. Our patient had PTH levels three times the upper limit of normal which are commonly seen in parathyroid carcinoma. Grossly, malignant parathyroid have whitish to grey hue versus reddish brown color in case of benign etiology which also directs surgical approach.

Efficacy and safety of total parathyroidectomy with autotransplantation vs. subtotal parathyroidectomy for secondary hyperparathyroidism: A retrospective study

BackgroundNo consensus has been reached on the best surgical approach for secondary hyperparathyroidism (SHPT). We evaluated the short-term and long-term efficacy and safety of total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX). MethodsWe retrospectively analyzed the data of 140 patients undergoing TPTX + AT and 64 undergoing SPTX between 2010 and 2021 in Second Affiliated Hospital of Soochow University, and carried out follow-up. We compared the differences in symptoms, serological examinations, complications and mortality between the two methods, and explored the independent risk factors of secondary hyperparathyroidism recurrence. ResultsIn short time after surgery, serum intact parathyroid hormone and calcium level was lower in TPTX + AT group than that in SPTX group (both P < 0.05). Severe hypocalcemia was more common in TPTX group (P = 0.003). The recurrent rate was 17.1% for TPTX + AT and 34.4% for SPTX (P = 0.006). There was no statistical difference in all-cause mortality, cardiovascular events, cardiovascular mortality between the two methods. Higher preoperative serum phosphorus level (HR: 1.929 95% CI 1.045–3.563, P = 0.011) and the SPTX surgical method (HR: 2.309, 95% CI 1.276–4.176, P = 0.006) were found to be independent risk factors for SHPT recurrence. ConclusionsCompared with SPTX, TPTX + AT is more effective in reducing the recurrent risk of SHPT without increasing the risk of all-cause mortality and cardiovascular events.