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The Journal of Clinical Endocrinology... May 2024Parathyroidectomy is recommended for curing primary hyperparathyroidism (PHPT), although uncertainty remains regarding the extent of fracture risk reduction following...
CONTEXT
Parathyroidectomy is recommended for curing primary hyperparathyroidism (PHPT), although uncertainty remains regarding the extent of fracture risk reduction following surgery.
OBJECTIVE
To compare fracture risk and bone mineral density (BMD) changes in patients with PHPT undergoing parathyroidectomy (PTX) versus observation (OBS).
DATA SOURCES
We systematically searched PubMed, Embase, and the Cochrane Library until September 2022, including randomized controlled trials (RCTs) and cohort studies, and reviewed citations from previous reviews.
STUDY SELECTION
Among 1,260 initial records, 48 eligible articles from 35 studies (5 RCTs; 30 cohorts) included PHPT patients receiving PTX or OBS interventions with reported fracture events at any site, including the hip, spine, or forearm, and/or BMD changes at each location.
DATA EXTRACTION
Following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines by two independent reviewers.
DATA SYNTHESIS
In 238,188 PHPT patients (PTX: 73,778 vs. OBS: 164,410), parathyroidectomy significantly reduced fractures at any site (RR, 0.80; 95%CI, 0.74-0.86) compared to observation. In 237,217 patients (PTX: 73,458 vs. OBS: 163,759), the risk of hip fractures decreased (RR, 0.63; 95%CI, 0.52-0.76). No reduction in forearm and vertebral fractures was observed in 3,574 and 3,795 patients, respectively. The annual percentage BMD changes from baseline were higher in the PTX group: femoral neck, 1.91% (95%CI, 1.14-2.68); hip, 1.75% (95%CI, 0.58-2.92); radius, 1.75% (95%CI, 0.31-3.18); spine, 2.13% (95%CI, 1.16-3.10).
CONCLUSIONS
Parathyroidectomy significantly reduced overall and hip fracture risks in PHPT patients. Despite minimal BMD increase, the substantial decrease in fracture risk suggests additional benefits of PTX beyond mineral content enhancement.
PubMed: 38739762
DOI: 10.1210/clinem/dgae326 -
Endocrine Nov 2023Multiple endocrine neoplasia type 1 (MEN1) is a rare syndrome that combines endocrine and non-endocrine tumors. Thymic neuroendocrine tumors are uncommon components that...
BACKGROUND
Multiple endocrine neoplasia type 1 (MEN1) is a rare syndrome that combines endocrine and non-endocrine tumors. Thymic neuroendocrine tumors are uncommon components that predict poor prognosis in patients with MEN1. We aimed to summarize the clinical characteristics of thymoma in MEN1 by reviewing the current reports from the literature.
METHODS
A patient with multiple endocrine neoplasia type 1 (parathyroid hyperplasia, pituitary adenoma, and insulinoma) was found to have a 2 × 1.5 cm thymic mass during long-term follow-up. Thoracoscope surgery was performed, and a histopathology examination revealed WHO Type B3 thymoma. A pathogenic mutation of c.783 + 1G > A in the MEN1 gene was identified. We further searched PubMed and EMBASE for thymoma in association with MEN1.
RESULTS
A comprehensive overview of the literature concerning characteristics of MEN1-related thymoma was summarized. Clinical characteristics and differences between thymoma and thymic carcinoid are highlighted.
CONCLUSIONS
Besides carcinoid, other tumors, including thymoma, need to be identified for thymic space-occupying lesions in MEN1 patients. The impact of thymoma on the long-term prognosis of MEN1 patients needs further investigation.
Topics: Humans; Multiple Endocrine Neoplasia Type 1; Thymoma; Thymus Neoplasms; Carcinoid Tumor; Pancreatic Neoplasms
PubMed: 37668926
DOI: 10.1007/s12020-023-03440-5 -
The Journal of Clinical Endocrinology... Oct 2023Secondary hyperparathyroidism (SHPT) is a complication of chronic kidney disease (CKD) affecting mineral and bone metabolism and characterized by excessive parathyroid... (Meta-Analysis)
Meta-Analysis
CONTEXT
Secondary hyperparathyroidism (SHPT) is a complication of chronic kidney disease (CKD) affecting mineral and bone metabolism and characterized by excessive parathyroid hormone (PTH) production and parathyroid hyperplasia.
OBJECTIVE
The objective of this analysis was to compare the efficacy and adverse effects of extended-release calcifediol (ERC) and paricalcitol (PCT) by assessing their effect on the biomarkers PTH, calcium, and phosphate in patients with non-dialysis CKD (ND-CKD).
METHODS
A systematic literature research was performed in PubMed to identify randomized control trials (RCTs). Quality assessment was done with the GRADE method. The effects of ERC vs PCT were compared using random effects in a frequentist setting.
RESULTS
Nine RCTs comprising 1426 patients were included in the analyses. The analyses were performed on 2 overlapping networks, due to nonreporting of outcomes in some of the included studies. No head-to-head trials were identified. No statistically significant differences in PTH reduction were found between PCT and ERC. Treatment with PCT showed statistically significant increases in calcium compared with ERC (0.2 mg/dL increase; 95% CI, -0.37 to -0.05 mg/dL). No differences in effects on phosphate were observed.
CONCLUSION
This network meta-analysis showed that ERC is comparable in lowering PTH levels vs PCT. ERC displayed avoidance of potentially clinically relevant increases in serum calcium, offering an effective and well-tolerated treatment option for the management of SHPT in patients with ND-CKD.
Topics: Humans; Calcifediol; Calcium; Ergocalciferols; Hyperparathyroidism, Secondary; Network Meta-Analysis; Parathyroid Hormone; Phosphates; Renal Insufficiency, Chronic; Randomized Controlled Trials as Topic
PubMed: 37235771
DOI: 10.1210/clinem/dgad289 -
JAMA Otolaryngology-- Head & Neck... Aug 2019Identifying parathyroid glands correctly before a surgical procedure is essential to perform minimally invasive surgery. First-line tests with discordant or negative...
IMPORTANCE
Identifying parathyroid glands correctly before a surgical procedure is essential to perform minimally invasive surgery. First-line tests with discordant or negative results underscore the need for more accurate imaging tests, thus decreasing the requirement for bilateral neck exploration or reintervention.
OBJECTIVE
To review the available evidence to determine positive predictive value, negative predictive value, sensitivity, and specificity in clinical cases in which 18F-fluorocholine positron emission tomography-computed tomography (PET/CT) could be useful as a method to locate the lesions, and the benefits and controversial aspects of the method.
EVIDENCE REVIEW
A search was conducted using the PubMed Central and Cochrane Library databases for studies published in English from July 26, 2014, to November 30, 2018, using the search terms 18 choline, 18F choline, 18F-choline, 18 fluorocholine PET CT, hyperparathyroidism, primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism, persistent hyperparathyroidism, recurrent hyperparathyroidism, ectopic hyperparathyroidism, and parathyroid adenoma. Other inclusion criteria were reporting at least 1 of the following measurements: negative or positive predictive value, sensitivity, and specificity of 18F-fluorocholine PET/CT in the diagnosis of hyperparathyroidism (HPT). Exclusion criteria were language other than English, use of a tracer other than 18F-fluorocholine, reports of a single case, and studies not related to HPT. The Oxford Centre classifications for levels of evidence were used.
FINDINGS
Sixteen studies fulfilled the inclusion criteria, comprising a total of 619 patients. Selected studies included 10 prospective cohort studies, 5 retrospective cohort studies, and 1 case series. Of the subtypes of HPT diagnosed using 18F-fluorocholine PET/CT, 579 were primary HPT, 22 were secondary HPT, 1 was tertiary HPT, and 7 were associated with multiple endocrine neoplasia type I. Pathologically, the neoplasms comprised 459 adenomas, 59 hyperplasia, and 19 double adenomas.
CONCLUSIONS AND RELEVANCE
18F-fluorcholine PET/CT may be indicated when results of first-line tests are negative or discordant and in challenging clinical situations where locating the source of HPT is difficult.
PubMed: 31145436
DOI: 10.1001/jamaoto.2019.0574 -
Seminars in Nuclear Medicine Jul 2006Hypersecretion of parathormone in primary hyperparathyroidism is common, occurring in approximately 1 in 500 women and 1 in 2,000 men per year in their fifth to seventh... (Review)
Review
Hypersecretion of parathormone in primary hyperparathyroidism is common, occurring in approximately 1 in 500 women and 1 in 2,000 men per year in their fifth to seventh decades of life. This has been suggested from the literature to be primarily the result of a parathyroid adenoma (80-85% of cases), hyperplasia involving more than 1 gland, usually with all 4 glands being involved (10-15% of cases), or the result, albeit rarely, of parathyroid carcinoma (0.5-1% of cases). Surgical removal of the hypersecreting gland is the primary treatment; this procedure is best performed by a skilled surgeon who would normally find the abnormality in 95% of cases. Imaging, however, should be used to identify the site of abnormality, potentially reducing inpatient stay and improving the patient experience. Functional imaging of parathyroid tissue using thallium was introduced in the 1980s but has largely been superceded by the use of (99m)Tc-labeled isonitriles. The optimum techniques have used (99m)Tc-sestamibi with subtraction imaging or washout imaging. A recent systematic review reported the percentage sensitivity (95% confidence intervals) for sestamibi in the identification of solitary adenomas as 88.44 (87.48-89.40), multigland hyperplasia 44.46 (41.13-47.8), double adenomas 29.95 (-2.19 to 62.09), and carcinoma 33 (33). This review does not separate the washout and subtraction techniques. The subtraction technique using (99m)Tc-sestamibi and (123)I is the optimal technique enabling the site to be related to the thyroid tissue when the parathyroid gland is in the neck in a normal position. If there is an equivocal scan then confirmation with high resolution ultrasound should be used. With ectopic glands, the combined use of single-photon emission computed tomography may then provide anatomical information to enable localization of the functional abnormality. In patients who have had surgical exploration by an experienced parathyroid surgeon in a unit with an experienced nuclear medicine team and negative sestamibi imaging, it is reasonable to image the patient with (11)C methionine. It is debatable whether patients with a high likelihood of secondary hyperparathyroidism should be imaged. The only possible justification for this is to exclude an ectopic site. There is no substitute for an experienced surgeon and an experienced imaging unit to provide a parathyroid service.
Topics: Adenoma; Adult; Aged; Choristoma; Diagnostic Imaging; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Neoplasms; Postoperative Complications; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Subtraction Technique
PubMed: 16762611
DOI: 10.1053/j.semnuclmed.2006.03.003 -
A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003.Otolaryngology--head and Neck Surgery :... Mar 2005To systematically review the current preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism. (Review)
Review
OBJECTIVE
To systematically review the current preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism.
STUDY DESIGN
A systematic literature review.
RESULTS
Of the 20,225 cases of primary hyperparathyroidism reported, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and parathyroid carcinomas (CAR) occurred in 88.90%, 5.74%, 4.14%, and 0.74% of cases respectively. Tc 99m -sestamibi and ultrasound were 88.44% and 78.55% sensitive, respectively, for SA, 44.46% and 34.86% for MGHD, and 29.95% and 16.20% for DA, respectively. Postoperative normocalcemia was achieved in 96.66%, 95.25%, and 97.69% of patients offered minimally invasive radio-guided parathyroidectomy (MIRP), unilateral, and bilateral neck exploration (BNE). Intraoperative PTH assays (IOPTH) were helpful in approximately 60% of bilateral neck exploration conversion (BNEC) surgeries.
CONCLUSION
The overall prevalence of multiple gland disease (MGD and DA) was lower than often suggested by conventional wisdom. Furthermore, preoperative imaging was less accurate than it is often perceived for accurately imaging MGD. MIRP and UNE were more successful in achieving normocalcemia than is typically quoted. IOPTH was a helpful but not "fool-proof" adjunct in parathyroid exploration surgery.
SIGNIFICANCE
These results support a greater role for the treatment of primary hyperparathyroidism using less invasive approaches. EMB rating: B-3.
Topics: Humans; Hyperparathyroidism
PubMed: 15746845
DOI: 10.1016/j.otohns.2004.10.005