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Problemy Endokrinologii Sep 2022Primary hyperparathyroidism (PHPT) is a significant endocrine disease caused by increased production of parathyroid hormone (PTH) by altered parathyroid glands and...
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.
Topics: Humans; Hyperparathyroidism, Primary; Diagnosis, Differential; Parathyroid Glands; Adenoma; Algorithms
PubMed: 36689712
DOI: 10.14341/probl13159 -
Sisli Etfal Hastanesi Tip Bulteni 2022In recent years, together with the contribution of new imaging methods, minimally invasive parathyroidectomy (MIP) has become the standard procedure in selected patients...
OBJECTIVES
In recent years, together with the contribution of new imaging methods, minimally invasive parathyroidectomy (MIP) has become the standard procedure in selected patients with the primary hyperparathyroidism (pHPT). However, some patients may still need bilateral neck exploration (BNE). In this study, we aimed to evaluate the factors associated with the necessity of BNE.
METHODS
Data of the patients, operated by same single surgeon in between 2010 and 2019, were evaluated retrospectively. Patients were divided into two groups as MIP group (group 1) and BNE group (group 2). The risk factors associated with necessity of BNE were evaluated.
RESULTS
Three hundred and forty-four patients (288 females and 56 males) were included in study. The mean age was 54.1±12.8. Pre-operative parathormone level (288 pg/mL vs. 190 pg/mL, p<0.001; respectively), compatible, inconsistent and negative imaging on scintigraphy (82.5% vs. 28.7%, 9.6% vs. 19.1, 7.9% vs. 52.25%, p<0.001; respectively), compatible, inconsistent and negative imaging in ultrasonography (USG) (72.9% vs. 20%, 7% vs. 19.1%, 20.1% vs 60.9%, p<0.001; respectively) in combination of USG and scintigraphy, two positive, single positive and negative imaging (72.5% vs. 11.3%, 25.8% vs. 55.7%, 1.7 vs. 33%, p<0.001; respectively), single adenoma, double adenoma, hyperplasia rates in pathology (96.1% vs. 79.1%, 3.1% vs. 12.2%, 0.9% vs. 8.7%, p<0.001; respectively), concomitant thyroidectomy (11.4% vs. 38.3%, p<0.001; respectively), diameter of the removed gland (2.03 vs. 1.58 cm, p<0.001; respectively), and volume of the removed gland (2.27 vs. 1.22 cm, p<0.001; respectively), were significantly different in group 1 compared to group 2. Low pre-operative parathormone, discordant pathological gland localization compared to pathological gland compatible with scintigraphy images (odds ratio [OR]: 3.690; p=0.027), negative scintigraphy images (OR: 9.174, p=0.000), and need for additional thyroidectomy (OR: 5.067); p=0.000) were determined as independent risk factors increasing the need for BNE in the multinomial logistic regression analysis. Long-term cure rates were similar (98.3% vs. 94.8%, p=0.079; respectively).
CONCLUSION
At present, BNE may be necessary in the surgical treatment of a significant proportion of patients with pHPT. According to our results, the possibility of BNE requirement is higher in patients with low PTH level compared to pre-operative high PTH values, in patients with discordant and negative scintigraphy compared to positive and compatible scintigraphy, and in patients who will undergo additional thyroidectomy. We think that BNE is not an alternative to MIP, but an effective option that is complementary to MIP to achieve optimal results in parathyroid surgery.
PubMed: 36660393
DOI: 10.14744/SEMB.2022.42492 -
Endocrinology, Diabetes & Metabolism... Jan 2023Hypercalcemia due to parathyroid carcinoma (PC) is safely and quickly controlled with rapidly increasing evocalcet doses. Most parathyroid carcinomas are detected...
SUMMARY
Hypercalcemia due to parathyroid carcinoma (PC) is safely and quickly controlled with rapidly increasing evocalcet doses. Most parathyroid carcinomas are detected because of hypercalcemia due to primary hyperparathyroidism (PHPT). Hypercalcemia becomes more severe in patients with PC than those with parathyroid adenoma or hyperplasia. Hypercalcemia often causes renal dysfunction, gastrointestinal symptoms, and psychiatric symptoms. Consequently, the serum calcium level needs to be promptly corrected. Here, we report a case of PC with remarkably persistent hypercalcemia, which we safely and quickly controlled with rapidly increasing evocalcet doses. A 77-year-old female presented with renal dysfunction. Her serum calcium (Ca) and intact parathyroid hormone serum levels were 13.9 mg/dL and 1.074 pg/mL, respectively. Her renal function worsened because of hypercalcemia due to PHPT. Technetium-99 m methoxy-isobutyl-isonitrile parathyroid scintigraphic examination revealed an accumulation below the right thyroid lobe. CT examination showed a 35-mm mass. Hypercalcemia needed to be immediately corrected because of the patient's worsening renal function. Evocalcet treatment at a gradually increasing dose of up to 20 mg over 3 weeks allowed her serum Ca level to be maintained below 11 mg/dL. Only mild nausea was observed at the beginning of the treatment. The mass was suspected as PC because the hypercalcemia was refractory to high-dose evocalcet. The patient was treated with parathyroidectomy and ipsilateral thyroidectomy. PC was diagnosed based on the pathological findings of capsular and venous invasion. The patient's renal function improved and surgery could be safely performed by promptly correcting hypercalcemia.
LEARNING POINTS
Hypercalcemia due to parathyroid carcinoma (PC) is often more severe than that caused by parathyroid adenoma or hyperplasia. PC is a rare disease, but it should be considered if the patient has intractable hypercalcemia due to primary hyperparathyroidism (PHPT). Evocalcet, which is used to treat hypercalcemia due to PHPT, does not interact with P450 (CYP) and causes few side effects. Complications, including renal dysfunction, were improved and the surgery could be safely performed by promptly correcting hypercalcemia. PC has a high recurrence rate. En-block excision is necessary when PC is suspected.
PubMed: 36602916
DOI: 10.1530/EDM-22-0269 -
Gland Surgery Nov 2022Primary hyperparathyroidism is a common endocrine disorder produced by the increase of parathyroid hormone (PTH) due to a benign adenoma of a single parathyroid gland,...
BACKGROUND
Primary hyperparathyroidism is a common endocrine disorder produced by the increase of parathyroid hormone (PTH) due to a benign adenoma of a single parathyroid gland, or as multiple gland hyperplasia, or as a rare malignant tumor. Preoperative imaging scans are frequently necessary for the minimally invasive parathyroidectomies to identify the location of enlarged parathyroid glands and to design the procedure.
METHODS
The diagnostic reliability of [F]fluorocholine positron emission tomography/computed tomography (FCH PET/CT), [Tc]sestamibi [multiplexed ion beam imaging (MIBI)] and cervical ultrasonography was analyzed in 37 patients diagnosed with primary hyperparathyroidism undergoing minimally invasive parathyroidectomy. The three preoperative imaging techniques were correlated with intraoperative and histopathological findings as well as changes in biochemical parameters (serum PTH and calcium levels). Statistical analysis was carried out with SPSS version 24.0.
RESULTS
In 30 of 37 patients (81.1%), FCH PET/CT correctly localized the pathological gland. In 3 cases of ectopic adenomas, the accuracy of the techniques was 100% (3/3) for FCH PET/CT, 66.7% (2/3) for MIBI, and 33.3% (1/3) for neck ultrasonography. Neither neck ultrasonography nor MIBI were able to locate pathological parathyroid glands in those patients with multiglandular disease, while FCH PET/CT correctly located one patient (1/3, 33.3%) with two adenomas and 3 patients (3/6, 50.0%) with hyperplasia. The three imaging techniques, FCH PET/CT, MIBI and neck ultrasound yielded a sensitivity of 92.1%, 57.9% and 32.4%, a positive predictive value of 94.6%, 84.6% and 78.6%, and a diagnostic accuracy of 96.4%, 85.7% and 79.0%, respectively.
CONCLUSIONS
In this group of patients diagnosed with primary hyperparathyroidism, FCH PET/CT was superior to MIBI and neck ultrasound in detecting adenomas, particularly in the presence of ectopic glands or multiglandular disease.
PubMed: 36518798
DOI: 10.21037/gs-22-198 -
Cureus Oct 2022Solitary parathyroid adenoma is the most common cause of primary hyperparathyroidism; however, multiple parathyroid adenomas are an uncommon phenomenon. In this case...
Solitary parathyroid adenoma is the most common cause of primary hyperparathyroidism; however, multiple parathyroid adenomas are an uncommon phenomenon. In this case report, we discuss a patient presenting with two concurrent ipsilateral parathyroid adenomas, and we review the literature. A 61-year-old African American female with a history of hypertension and kidney stones presented for the evaluation of hypercalcemia. Elevated serum calcium of 11 mg/dL was found on routine laboratory tests and low25 hydroxyvitamin-D level. Parathyroid hormone (PTH) was elevated at 172.5 pg/mL and increased to 443 pg/mL after correction of vitamin D deficiency. Renal function tests and thyroid function tests revealed normal findings. Imaging studies with 99mTc-Sestamibi scintigraphy raised concern for the possibility of either a parathyroid adenoma or hyperplasia. Minimally invasive parathyroidectomy with intraoperative PTH monitoring was planned. During surgery, the right superior parathyroid gland was found to be enlarged and was excised. However, intraoperative PTH monitoring showed an initial decrease to 203 pg/mL from a baseline of 443 pg/mL and a subsequent increase to 293 pg/mL suggesting the persistence of hyperparathyroidism. Further exploration of the neck revealed an enlarged right inferior parathyroid gland and two normal left parathyroid glands. Intraoperative PTH monitoring then revealed an appropriate decrease in PTH level to 56 pg/mL 10 minutes after excision of the right inferior parathyroid gland. More than a 50% decrease in PTH was achieved, and further exploration of the opposite side revealed no evidence of four-gland hyperplasia. Pathology reported two concurrent right superior and inferior parathyroid adenomas. Successful and curative parathyroidectomy for primary hyperparathyroidism was achieved. Although rare, multiple parathyroid adenomas occur in a significant minority of cases. Intraoperative PTH monitoring along with preoperative imaging provides guidance for curative parathyroidectomy. Additionally, more sensitive imaging such as four-dimensional computed tomography scans could lead to better localization, visualization, and identification of the second parathyroid adenoma.
PubMed: 36457632
DOI: 10.7759/cureus.30854 -
Journal of Clinical Medicine Nov 2022To compare the safety and efficacy of percutaneous paricalcitol injection with intravenously administered paricalcitol in treating parathyroid hyperplasia in patients...
PURPOSE
To compare the safety and efficacy of percutaneous paricalcitol injection with intravenously administered paricalcitol in treating parathyroid hyperplasia in patients with secondary hyperparathyroidism (SHPT).
METHODS
This study was approved by the Ethics Committee of our institution. We retrospectively collected data on patients who received percutaneous paricalcitol injection (24 patients) and intravenously administered paricalcitol (22 patients) based on their intact parathyroid hormone (iPTH) level. Serum iPTH, calcium, phosphorus, and the volume of the parathyroid gland were measured at several indicated time points after treatment, and adverse events associated with the two treatments were evaluated.
RESULTS
After 6 months of follow-up, we found that patients from the percutaneous injection group had significantly decreased levels of iPTH (from 1887.81 ± 726.81 pg/mL to 631.06 ± 393.06 pg/mL), phosphate (from 1.94 ± 0.36 mmol/L to 1.71 ± 0.34 mmol/L), and volume of the parathyroid gland (from 0.87 ± 0.50 cm to 0.60 ± 0.36 cm), with relief from ostealgia within 48-72 h. In the intravenously administered group, the levels of iPTH decreased from 686.87 ± 260.44 pg/mL to 388.47 ± 167.36 pg/mL; while there was no significant change in phosphate levels, the volume of the parathyroid gland and ostealgia relief were observed at the end of follow-up. The serum calcium level did not significantly change, and no severe complications were observed in both groups. In vitro fluorescence-activated single cell sorting (FACS) analysis indicated that paricalcitol induced parathyroid cell apoptosis in a dose-dependent manner.
CONCLUSIONS
Percutaneous paricalcitol injection is a selective treatment for SHPT in ESRD.
PubMed: 36431337
DOI: 10.3390/jcm11226860 -
Medicine Nov 2022Secondary parathyroid hyperplasia canceration is very rare and thus easily be overlooked during parathyroid ultrasound examination. However, secondary parathyroid...
INTRODUCTION
Secondary parathyroid hyperplasia canceration is very rare and thus easily be overlooked during parathyroid ultrasound examination. However, secondary parathyroid hyperplasia still has the possibility of canceration, and it is still important to be alert to its occurrence when performing ultrasound examinations and clinical treatment.
PATIENT CONCERNS
A 49-years-old man visited our outpatient department with generalized weakness and pain in both lower extremities a month ago.
DIAGNOSIS
Hyperparathyroidism secondary to chronic renal failure.
INTERVENTIONS
The patient underwent ultrasound and other preoperative examinations. The preoperative ultrasound showed 3 parathyroid enlargements, 2 on the left and 1 on the right. The patient then underwent surgical treatment.
OUTCOMES
Ultrasonography suggested the presence of 3 parathyroid hyperplasias, and ectopic right inferior parathyroid gland was visible during intraoperative examination. 10 days after surgery, the patient's Parathyroid Hormone returned to the normal range.
CONCLUSION
Secondary parathyroid hyperplasia has the potential to become cancerous, so doctors should be alert to its occurrence when conducting ultrasound examinations. Ultrasound examination is the key to its diagnosis and subsequent treatment.
Topics: Humans; Male; Middle Aged; Hyperplasia; Parathyroid Neoplasms; Parathyroid Glands; Hyperparathyroidism, Primary; Carcinoma
PubMed: 36401397
DOI: 10.1097/MD.0000000000031362 -
Bone Feb 2023Secondary hyperparathyroidism (SHPT) is a major comorbidity of chronic kidney disease (CKD). Chronic elevation of PTH levels is associated with cortical bone...
Upacicalcet, a positive allosteric modulator of the calcium-sensing receptor, prevents vascular calcification and bone disorder in a rat adenine-induced secondary hyperparathyroidism model.
Secondary hyperparathyroidism (SHPT) is a major comorbidity of chronic kidney disease (CKD). Chronic elevation of PTH levels is associated with cortical bone deterioration and increase in the risk of fractures in CKD patients. Here, we evaluated the effect of repeated administration of upacicalcet, a novel positive allosteric modulator of the calcium-sensing receptor, in a rat model of adenine-induced renal failure, by determining serum levels of intact PTH (iPTH), calcium, phosphorus, creatinine, and urea nitrogen. Furthermore, parathyroid hyperplasia (parathyroid gland weight and Ki-67-positive cell density), ectopic calcification (calcium content in the thoracic aorta, kidney and heart and positive von Kossa staining in the thoracic aorta), and bone morphometry parameters (cortical porosity and fibrosis volume) were evaluated. Rats treated with either 0.2 mg/kg or 1 mg/kg upacicalcet exhibited significantly lower serum iPTH levels than CKD-control rats, as early as 7 days after the first dose. Repeated administration of upacicalcet reduced serum iPTH levels and inhibited parathyroid hyperplasia in rats with adenine-induced severe renal failure. Moreover, it suppressed ectopic calcification and cortical pore formation. In contrast, serum calcium and phosphorus levels were not significantly affected, suggesting a low risk of hypocalcemia, which often occurs with SHPT treatment. In conclusion, repeated administration of upacicalcet decreased serum iPTH levels and suppressed parathyroid hyperplasia in the adenine-induced CKD rat model of SHPT. Furthermore, ectopic calcification and cortical pore formation were suppressed without significant changes in blood mineral parameters. Upacicalcet safely inhibited the progression of SHPT in an adenine-induced CKD rat model.
Topics: Rats; Animals; Calcium; Receptors, Calcium-Sensing; Hyperplasia; Adenine; Hyperparathyroidism, Secondary; Vascular Calcification; Bone Diseases; Renal Insufficiency, Chronic; Phosphorus; Renal Insufficiency; Parathyroid Hormone
PubMed: 36395959
DOI: 10.1016/j.bone.2022.116613 -
Frontiers in Pharmacology 2022A common consequence of chronic renal disease is secondary hyperparathyroidism (SHPT) and is closely related to the mortality and morbidity of uremia patients. Secondary... (Review)
Review
A common consequence of chronic renal disease is secondary hyperparathyroidism (SHPT) and is closely related to the mortality and morbidity of uremia patients. Secondary hyperparathyroidism (SHPT) is caused by excessive PTH production and release, as well as parathyroid enlargement. At present, the mechanism of cell proliferation in secondary hyperparathyroidism (SHPT) is not completely clear. Decreased expression of the vitamin D receptor (VDR) and calcium-sensing receptor (CaSR), and 1,25(OH)2D3 insufficiency all lead to a decrease in cell proliferation suppression, and activation of multiple pathways is also involved in cell proliferation in renal hyperparathyroidism. The interaction between the parathormone (PTH) and parathyroid hyperplasia and 1,25(OH)2D3 has received considerable attention. 1,25(OH)2D3 is commonly applied in the therapy of renal hyperparathyroidism. It regulates the production of parathormone (PTH) and parathyroid cell proliferation through transcription and post-transcription mechanisms. This article reviews the role of 1,25(OH)2D3 in parathyroid cells in secondary hyperparathyroidism and its current understanding and potential molecular mechanism.
PubMed: 36267284
DOI: 10.3389/fphar.2022.1020858 -
Gland Surgery Sep 2022Sagliker syndrome is caused by severe secondary hyperparathyroidism in hemodialysis patients with chronic renal failure. It is mainly manifested by disturbances of...
BACKGROUND
Sagliker syndrome is caused by severe secondary hyperparathyroidism in hemodialysis patients with chronic renal failure. It is mainly manifested by disturbances of calcium and phosphorus metabolism and bone changes, which eventually lead to abnormal changes in facial appearance and morphology, seriously affecting the quality of life of patients. With the improvement of management mode and technology for hemodialysis in chronic renal failure, the incidence of severe secondary hyperparathyroidism related to hemodialysis is relatively reduced. Therefore, Sagliker syndrome is more rare. How to early identify and choose the appropriate treatment for Sagliker syndrome is particularly important.
CASE DESCRIPTION
A 34-year-old female patient with uremia, who underwent regular hemodialysis at the Blood Purification Center of Tianjin Third Central Hospital, developed Sagliker syndrome. The general data, clinical symptoms, height changes, biochemical indicators (serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, hemoglobin, and hematocrit), and parathyroid emission computerized tomography (ECT) were collected and analyzed. The patient had a history of hemodialysis with chronic renal failure for 6 years, and presented with bone pain for 2 years. Laboratory tests showed parathyroid hormone was 2,269 pg/mL and ECT showed 3 parathyroid hyperplasia. Finally, total parathyroidectomy and forearm transplantation were performed. The level of parathyroid hormone was significantly lower than that before the operation. On the first postoperative day, the level of parathyroid hormone decreased to 28.3 pg/mL. Four months later, the bone pain symptoms of the patient were significantly improved compared with those before the operation.
CONCLUSIONS
Sagliker syndrome is a special syndrome in maintenance hemodialysis patients with refractory secondary hyperparathyroidism. Early monitoring and standardized treatment of secondary hyperparathyroidism may prevent the occurrence of Sagliker syndrome. Early identification and diagnosis of Sagliker syndrome and the choice of appropriate treatment will have an important impact for the prognosis.
PubMed: 36221284
DOI: 10.21037/gs-22-479