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Chuang F, Ng SK, Khan R, Lam AKY. Relationship between parathyroid adenoma size, weight and histological subtypes with perioperative serum levels. J Clin Pathol 2024:jcp-2023-209340. [PMID: 38821854 DOI: 10.1136/jcp-2023-209340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/09/2024] [Indexed: 06/02/2024]
Abstract
AIMS This study aims to identify associations between parathyroid adenoma (PTA) characteristics (histology, weight and size) with the change in parathyroid hormone (PTH) and calcium levels. METHODS A historical cohort study was conducted on adult patients with solitary PTA removed in the Gold Coast Health Precinct, Australia, between 2017 and 2022. RESULTS PTA weight is correlated with the change in day 1 PTH level (r=0.26, p=0.036), the change in day 1 corrected calcium level (r=0.20, p=0.033), and the change in follow-up corrected calcium level (r=0.47, p<0.001). The largest dimension (size) of PTA is also correlated with the change in day 1 PTH (r=0.30, p=0.011) and the change in follow-up corrected calcium level (r=0.40, p<0.001). Adjusted for age and gender, a statistically significant negative correlation was found between day 1 PTH level and adenoma size, resulting in a 0.5% change in size for every percentage change in PTH level (equating to a 5.0% increase in variance explained, p=0.038). Similarly, a negative correlation was identified in day 1 corrected calcium levels and weight, with a 4.7% change in weight for every percentage of change in day 1 corrected calcium level (an increase of 5.6% variance explained, p=0.010). In addition, a negative correlation was identified, where every 3.1% change in size (an increase of 17.4% variance explained, p<0.001) and 7.6% change in weight (an increase of 22.7% variance explained, p<0.001) was seen with every percentage change in follow-up corrected calcium levels. Clear-cell PTA had the most significant percentage fall in day 1 corrected calcium levels compared with other PTA subtypes (p=0.007). CONCLUSIONS Preoperative calcium and PTH levels correlate with PTA weight and size. The degree of change in postoperative corrected calcium levels behaved differently in the clear-cell subtype.
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Affiliation(s)
- Fred Chuang
- Griffith University Griffith Health, Gold Coast, Queensland, Australia
| | - Shu Kay Ng
- Griffith University Griffith Health, Gold Coast, Queensland, Australia
| | - Roger Khan
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Alfred King-Yin Lam
- Griffith University Griffith Health, Gold Coast, Queensland, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
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Law RH, Larrabee KA, Stefan AJ, Quan DL, Peterson EL, Singer MC. Intraoperative Parathyroid Hormone Monitoring In Normohormonal Primary Hyperparathyroidism: How Low Do You Go? Laryngoscope 2024; 134:2480-2484. [PMID: 37772923 DOI: 10.1002/lary.31076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/24/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE The primary goal of this study was to determine in patients with normohormonal primary hyperparathyroidism (NHHPT) what percent reduction in post-excision intraoperative parathyroid hormone (IOPTH) from baseline would yield a rate of cure comparable to that in patients with classical primary hyperparathyroidism (PHPT). METHODS This is a retrospective cohort study of patients who underwent parathyroidectomy between July 2013 and February 2020. Demographic data, preoperative, intraoperative, and postoperative metrics were collected. Patients with NHHPT were compared to those with classical PHPT. Subgroup analyses were performed. RESULTS Of the 496 patients included in the study, 66 (13.3%) were of the normohormonal variant based on preoperative intact parathyroid hormone (PTH) levels and 28 (5.6%) based on baseline IOPTH levels. The cure rates in the two normohormonal groups were not significantly different from their classical counterparts (98.4% and 100.0% vs. 97.1%, p = 1.000). The median percent decline in post-excision IOPTH from baseline that achieved cure in the normohormonal groups were 82.6% and 80.4% compared to their respective controls at 87.3%, p = 0.011 and p = 0.001. Although the rate of multiglandular disease was higher in one of the normohormonal variant groups, this difference was due to a higher rate of double adenomas, not four-gland hyperplasia. CONCLUSION Patients with NHHPT undergoing parathyroidectomy can expect cure rates similar to that in patients with classical PHPT. The results of this study indicate that achieving an 80% drop or more in IOPTH levels predicts a high likelihood of cure. This is true irrespective of whether the patient is deemed normohormonal based on preoperative or intraoperative testing. LEVEL OF EVIDENCE 3 Laryngoscope, 134:2480-2484, 2024.
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Affiliation(s)
- Richard H Law
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Katherine A Larrabee
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Andrew J Stefan
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Daniel L Quan
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Edward L Peterson
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan, USA
| | - Michael C Singer
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
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Lapeña-Rodríguez M, Cassinello-Fernández N, Alfonso-Ballester R. Primary hyperparathyroidism with normal parathormone levels: Presentation of 2 cases. Med Clin (Barc) 2024; 162:201-202. [PMID: 37985329 DOI: 10.1016/j.medcli.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 11/22/2023]
Affiliation(s)
| | - Norberto Cassinello-Fernández
- Endocrine and Bariatric Surgery Unit, Hospital Clínico Universitario, Valencia, Spain; Department of Surgery, University of Valencia, Spain
| | - Raquel Alfonso-Ballester
- Endocrine and Bariatric Surgery Unit, Hospital Clínico Universitario, Valencia, Spain; Department of Surgery, University of Valencia, Spain
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Nabata KJ, Wiseman JJ, Wiseman SM. Normohormonal primary hyperparathyroidism: A systematic review and meta-analysis. Am J Surg 2023; 226:186-196. [PMID: 37100740 DOI: 10.1016/j.amjsurg.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/15/2023] [Accepted: 04/08/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE We aim to evaluate the body of evidence reporting on normohormonal primary hyperparathyroidism (NHpHPT) patients to help guide their diagnosis, characterization and treatment. BACKGROUND Normohormonal primary hyperparathyroidism is a term used to describe patients with a normal PTH and elevated calcium levels. There is limited understanding regarding the presentation and appropriate management of these patients. METHODS A systematic review was conducted: abstract and full-text screening were independently conducted by 2 investigators. Odds ratios (OR), standard mean differences (SMD) and 95% confidence intervals were calculated. RESULTS Twenty-two studies were identified. Patients with NHpHPT were more likely to present with lower PTH (p < 0.00001) and calcium (p < 0.00001) levels. Intraoperatively, the NHpHPT group was 1.8 times more likely to undergo bilateral neck exploration (BNE) and harbor multigland disease. The rates of surgical cure were 93% in the NHpHPT and 96% in the pHPT groups (p = 0.0003). CONCLUSION Symptomatic patients with NHpHPT benefit from parathyroidectomy with prolonged intraoperative PTH monitoring, and a low threshold for conversion to BNE.
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Affiliation(s)
- Kylie J Nabata
- Department of Surgery, St. Paul's Hospital & University of British Columbia, C303-1081 Burrard St, Vancouver, British Columbia, V6Z 1Y6, Canada.
| | - Jacob J Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, C303-1081 Burrard St, Vancouver, British Columbia, V6Z 1Y6, Canada.
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, C303-1081 Burrard St, Vancouver, British Columbia, V6Z 1Y6, Canada.
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Hypercalcemia with a parathyroid hormone level of ≤50 pg/mL: Is this primary hyperparathyroidism? Surgery 2023; 173:154-159. [PMID: 36202653 DOI: 10.1016/j.surg.2022.05.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary hyperparathyroidism is characterized by hypercalcemia with inappropriately normal or elevated parathyroid hormone. However, the absolute parathyroid hormone value that is defined as inappropriately normal is unclear. We reviewed our experience with parathyroidectomy in patients with hypercalcemia and parathyroid hormone of ≤50.0 pg/mL (normal range 12.0-88.0 pg/mL). METHODS A total of 2,349 patients underwent parathyroidectomy for primary hyperparathyroidism between 2000 and 2021. Of these, 149 patients had preoperative parathyroid hormone ≤50.0 pg/mL (parathyroid hormone ≤50). The biology and outcomes were compared to patients with parathyroid hormone >50.0 pg/mL (parathyroid hormone >50). RESULTS Of the parathyroid hormone ≤50 patients, the median parathyroid hormone was 40.0 pg/mL (range 11.6-50.0 pg/mL). All patients were found to have abnormal hypercellular parathyroid glands with a cure rate of 96.7%. When compared to the parathyroid hormone >50 group, the parathyroid hormone ≤50 group was younger (56 ± 15 vs 60 ± 14 years, P < .001) with a lower body mass index (28.7 ± 7.0 kg/m2 vs 31.2 ± 7.9 kg/m2, P < .001), higher rate of fatigue (73.2% vs 63.0%, P = .033), and higher rate of multiglandular disease (58.9% vs 31.9%, P < .001). There was no difference between the groups with respect to patient demographics, rate of previous parathyroidectomy, surgical cure, or postoperative complications (persistent or recurrent hyperparathyroidism and hypocalcemia). CONCLUSION Patients with hypercalcemia and parathyroid hormone ≤50 pg/mL have a similar clinical presentation and rate of surgical cure to other primary hyperparathyroidism patients and should be considered for parathyroidectomy. Most of these patients have multiglandular disease and thus should be considered for bilateral parathyroid exploration.
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Medina JE, Randolph GW, Angelos P, Zafereo ME, Tufano RP, Kowalski LP, Montenegro FLM, Owen RP, Khafif A, Suárez C, Shaha AR, Rodrigo JP, Krempl GA, Rinaldo A, Silver CE, Ferlito A. Primary hyperparathyroidism: Disease of diverse genetic, symptomatic, and biochemical phenotypes. Head Neck 2021; 43:3996-4009. [PMID: 34541734 DOI: 10.1002/hed.26861] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 07/08/2021] [Accepted: 08/12/2021] [Indexed: 12/12/2022] Open
Abstract
Genetic, symptomatic, and biochemical heterogeneity of patients with primary hyperparathyroidism (PHPT) has become apparent in recent years. An in-depth, evidence-based review of the phenotypes of PHPT was conducted. This review was intended to provide the resulting information to surgeons who operate on patients with hyperparathyroidism. This review revealed that the once relatively clear distinction between familial and sporadic PHPT has become more challenging by the finding of various germline mutations in patients with seemingly sporadic PHPT. On the one hand, the genetic and clinical characteristics of some syndromes in which PHPT is an important component are now better understood. On the other hand, knowledge is emerging about novel syndromes, such as the rare multiple endocrine neoplasia type IV (MEN4), in which PHPT occurs frequently. It also revealed that, currently, the classical array of symptoms of PHPT is seen rarely upon initial presentation for evaluation. More common are nonspecific, nonclassical symptoms and signs of PHPT. In areas of the world where serum calcium levels are checked routinely, most patients today are "asymptomatic" and they are diagnosed after an incidental finding of hypercalcemia; however, some of them have subclinical involvement of bones and kidneys, which is demonstrated on radiographs, ultrasound, and modern imaging techniques. Last, the review points out that there are three distinct biochemical phenotypes of PHPT. The classical phenotype in which calcium and parathyroid hormone levels are both elevated, and other disease presentations in which the serum levels of calcium or intact parathyroid hormone are normal. Today several, distinct phenotypes of the disease can be identified, and they have implications in the diagnostic evaluation and treatment of patients, as well as possible screening of relatives.
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Affiliation(s)
- Jesus E Medina
- Department of Otolaryngology and Head and Neck Surgery, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA
| | - Mark E Zafereo
- Head and Neck Endocrine Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Luiz P Kowalski
- Department of Head and Neck Surgery, University of Sao Paulo Medical School, São Paulo, Brazil.,Head and Neck Surgery and Otorhinolaryngology Department, A. C. Camargo Cancer Center, São Paulo, Brazil
| | - Fabio L M Montenegro
- Department of Head and Neck Surgery, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Randall P Owen
- Division of Surgical Oncology, Department of Surgery, Mount Sinai School of Medicine, New York, New York, USA
| | - Avi Khafif
- Head and Neck Surgery and Oncology Unit, A.R.M. Center for Advanced Otolaryngology Head and Neck Surgery, Assuta Medical Center, Tel Aviv, Israel
| | - Carlos Suárez
- Instituto de Investigación Sanitaria del Principado de Asturias, IUOPA, CIBERONC, Oviedo, Spain
| | - Ashok R Shaha
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Juan P Rodrigo
- University of Oviedo, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Greg A Krempl
- Department of Otolaryngology and Head and Neck Surgery, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | | | - Carl E Silver
- Department of Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
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Lecourt A, Creff G, Coudert P, De Crouy Chanel O, Guggenbuhl P, Jegoux F. Surgical management of MILD hyperparathyroidism. Eur Arch Otorhinolaryngol 2021; 278:3901-3910. [PMID: 34328555 DOI: 10.1007/s00405-021-06953-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There is no consensus for management of Mild primary hyperparathyroidism (MILD-pHP). Specific management has been suggested by some authors. We have compared the surgical management of the patients with MILD-pHP to those with Classic primary hyperparathyroidism (C-pHP) treated by surgery according to The Fourth International Workshop on pHP. MATERIALS AND METHODS Data of 173 patients who underwent a parathyroidectomy were reviewed and retrospectively analysed. Management of 32 patients with MILD-pHPT (18.5%) patients were compared to that of 141 (81.5%) patients with C-pHPT. RESULTS MILD-pHP group was more often discovered after non-fractured osteoporosis (21.9% vs 7.1%, p = 0.02) and surgery for chondrocalcinosis was more often carried out (6.3% vs 0%, p = 0.03) in the MILD-pHP group. A Mini-Invasive Parathyroidectomy (MIP) was carried out in 81.3% of cases, and 87.5% of patients had a single adenoma. The rate of multiglandular pathology was not different. Same day discharge was significantly higher in MILD-pHP group (37.5% vs 17.7%, p = 0.01). Success was obtained in 87.5% in the MILD-pHP group, there was no significant difference with the C-pHP group (92.9%, p = 0.48). There was no significant difference in the imaging performances. Imaging discordance was observed in 18.8% of cases in MILD-pHP and 33.6% in C-pHP (p = 0.38) without correlation with surgical failure. CONCLUSION This study suggests that, by selecting patients on the basis of concordant imaging and international recommendations, there is no difference in outcome between MILD-pHP and C-pHP treated surgically.
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Affiliation(s)
- Adèle Lecourt
- ENT Department, Rennes University Medical Center, 35000, Rennes, France. .,Service d'ORL et de Chirurgie Cervico-Faciale, CHU de Rennes, 2 Rue Henri Le Guilloux, 35000, Rennes Cedex, France.
| | - Gwenaëlle Creff
- ENT Department, Rennes University Medical Center, 35000, Rennes, France
| | - Paul Coudert
- ENT Department, Rennes University Medical Center, 35000, Rennes, France
| | | | - Pascal Guggenbuhl
- Rheumatologic Department, Rennes University Medical Center, Rennes 1 University, INSERM, Institut NUMECAN (Nutrition Metabolisms and Cancer), 35000, Rennes, France
| | - Franck Jegoux
- ENT Department, Rennes University Medical Center, 35000, Rennes, France
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Szulc P. Biochemical bone turnover markers in hormonal disorders in adults: a narrative review. J Endocrinol Invest 2020; 43:1409-1427. [PMID: 32335857 DOI: 10.1007/s40618-020-01269-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/18/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hormonal disorders are often associated with abnormal levels of bone turnover markers (BTMs). N-terminal propeptide of type I procollagen (PINP) and serum C-terminal cross-linking telopeptide of type I collagen (CTX-I) are the reference markers of bone formation and bone resorption, respectively. METHODS A comprehensive literature search within the MEDLINE and Web of Science databases was performed. RESULTS Acromegaly is associated with higher BTM levels, which decrease during the remission after treatment. Adult-onset growth hormone deficiency is often associated with decreased BTM levels. Growth hormone replacement therapy stimulates bone turnover and increases BTM levels. Hypothyroidism is characterized by general slowing of bone metabolism which is reflected by lower BTM levels. The replacement thyroid hormone therapy increases the bone turnover rate and BTM levels increase. Patients with thyroid cancer receive a suppressive dose of thyroid hormones and may have slightly elevated BTM levels. Patients with overt hyperthyroidism had higher BTM levels and anti-thyroid therapy induces a rapid decrease in the BTM levels. Patients with overt primary hyperparathyroidism have higher BTM levels, whereas those with asymptomatic and normocalcemic hyperparathyroidism usually have normal BTM levels. Hypoparathyroidism is characterized by slightly decreased BTM levels. Cushing's syndrome is characterized consistently by markedly decreased osteocalcin concentration, whereas data on other BTMs are discordant. CONCLUSIONS BTMs help us to better understand mechanisms of the impact of hormonal disorders and their treatment on bone metabolism. However, it is unknown whether BTMs may be used to monitor the effect of their treatments on bone in the clinical practice.
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Affiliation(s)
- P Szulc
- INSERM UMR 1033, University of Lyon, Hôpital Edouard Herriot, Pavillon F, Place d'Arsonval, 69437, Lyon, France.
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Naples R, Shin JJ, Berber E, Jin J, Krishnamurthy VD, Siperstein AE. Recognition of primary hyperparathyroidism: Delayed time course from hypercalcemia to surgery. Surgery 2020; 167:358-364. [DOI: 10.1016/j.surg.2019.07.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022]
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Medas F, Erdas E, Loi G, Podda F, Barca L, Pisano G, Calò PG. Intraoperative parathyroid hormone (PTH) testing in patients with primary hyperparathyroidism and PTH levels in the normal range. BMC Surg 2019; 18:124. [PMID: 31074404 PMCID: PMC7402568 DOI: 10.1186/s12893-018-0459-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Primary hyperparathyroidism is a common endocrine disorder. Hypercalcemia with normal PTH levels is very unusual and can lead to diagnostic difficulties. There are very few very few studies in the literature and all with limited numerical samples. The goal of the present study was to determine the real incidence and characteristics of primary hyperparathyroidism with normal PTH and to evaluate if intraoperative PTH testing is useful in these patients. Methods We performed a retrospective review of 314 patients who had undergone parathyroidectomy to treat primary hyperparathyroidism between January 2002 and December 2016. Patients were divided in two groups according to biochemical preoperative findings: in Group A were included patients with normal serum PTH, in Group B those with increased serum PTH. Results Nine patients (3.7%) were included in group A and 235 in group B. Patients in group A were younger (51.5 ± 12.9 years vs 59.6 ± 12.5); preoperative serum calcium and the incidence of coexisting thyroid disease were similar between the two groups. Symptomatic patients were more frequent in Group A (77.8% vs 39.1%; p = 0.048). There were no significant differences regarding preoperative localization studies and surgical procedure. Intraoperative PTH determination demonstrated sensitivity of 86% in group A and 97% in group B, specificity and positive predictive value of 100% in both the groups, negative predictive value of 67% in group A and 79% in group B. Histopathological examination demonstrated a single gland disease in 8 (88.9%) patients in group A and a multi gland disease in 1 (11.1%), in group B single gland disease was found in 218 (92.8%) patients and multi gland disease in 17 (7.2%). Unsuccessful surgery with persistent or recurrent hyperparathyroidism occurred in 1 (11.1%) patient in group A and 4 (1.7%) in group B. Conclusions Primary hyperparathyroidism with normal PTH is rare but physicians should be aware of this possibility in patients with hypercalcaemia. Patients with normal PTH levels are younger and more frequently symptomatic. Intraoperative PTH testing plays an important role in the operative management even in such patients.
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Affiliation(s)
- Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Enrico Erdas
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Giulia Loi
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Francesco Podda
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Lucia Barca
- Center for the Study of Liver Diseases, Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Giuseppe Pisano
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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Kiriakopoulos A, Petralias A, Linos D. Classic Primary Hyperparathyroidism Versus Normocalcemic and Normohormonal Variants: Do They Really Differ? World J Surg 2018; 42:992-997. [PMID: 29392434 DOI: 10.1007/s00268-018-4512-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Normocalcemic (NCpHPT) and normohormonal (NHpHPT) variants have been recognized primary hyperparathyroidism entities that pose serious challenges. We sought to define the differences among them in a series of surgically treated patients. PATIENTS AND METHODS Between 2011 and 2015, 149 patients were enrolled into three groups: CpHPT (Ca > 10.2 mg/dL, PTH > 65 pg/mL), NCpHPT (normal Ca, PTH > 65 pg/mL) and NHpHPT (Ca > 10.2 mg/dL, normal PTH). Descriptive statistics and inter-group differences were computed, whereas multiple logistic/linear regression tests were used for further analysis. RESULTS Of these patients 125 were female and 24 male, mean age 56.3 years (range 8-83). A total of 115 (77.2%) patients presented with CpHPT, 23 (15.4%) with NCpHPT and 11 (7.4%) with NHpHPT. MGD was found in 25 (16.8%) patients and SGD in 124 (83.2%); multivariate analysis failed to reveal statistically significant association of MGD with any pHPT variant (CpHPT 16.5% vs NCpHPT 21.7% vs NHpHPT 9.1%, p = 0.726). Conversely, NCpHPT patients exhibited statistically significant smaller adenoma weight (p = 0.023). Moreover, U/S in these patients had smaller positive predictive value (p = 0.278), whereas concordance between U/S and MIBI was also lower (p = 0.669). The utility of MIBI and U/S differed significantly (p < 0.001); more frequent use of U/S was observed for all groups. However, their predictive values did not differ significantly (p = 0.832). CONCLUSIONS NCpHPT is more similar than different to CpHPT. NCpHPT constitutes the most challenging entity: it is associated with smaller adenoma weight, whereas U/S exhibited lower positive predictive value and lower concordance rate with MIBI. A trend for higher MGD presence in this group of patients was observed, though without statistical significance.
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Affiliation(s)
- Andreas Kiriakopoulos
- Department of Surgery, 5th Surgical Clinic, Evgenidion Hospital, National and Kapodistrian University of Athens Medical School, Papadiamantopoulou 20 Str., 11528, Athens, Greece.
| | - Athanasios Petralias
- Institute of Preventive Medicine, Environmental and Occupational Health-Prolepsis, Athens, Greece
| | - Dimitrios Linos
- Department of Surgery, 5th Surgical Clinic, Evgenidion Hospital, National and Kapodistrian University of Athens Medical School, Papadiamantopoulou 20 Str., 11528, Athens, Greece
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Pang C, Fan Y, Zhang H, Yu H, Guo B, Kang J, Deng X, Bao Y. Case report: incidental parathyroid adenoma in a Chinese diabetic patient with hypercalcemia and normal parathyroid hormone levels. Medicine (Baltimore) 2018; 97:e11333. [PMID: 29995768 PMCID: PMC6076047 DOI: 10.1097/md.0000000000011333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Parathyroid hormone PTH) levels are the main parameters to differentiate primary hyperparathyroidism (PHPT) from non-PTH-dependent hypercalcemia. We report a case of hypercalcemia with normal PTH levels due to a parathyroid adenoma. PATIENT CONCERNS A 52-year-old female patient presented with 2-year history of documented sustained high-normal serum calcium and hypercalcemia (2.51-3.03 mmol/L) with normal serum intact PTH levels (21.95-40.15 pg/ mL). DIAGNOSES A parathyroid tumor was localized by ultrasonography and 99mTc-sestamibi dual-phase fusion imaging with single-photon emission computed tomography/computed tomography. INTERVENTIONS Parathyroidectomy was performed to excise the tumor completely. OUTCOMES A 1.2-cm-sized parathyroid adenoma was removed surgically. The serum calcium was declined to normal level immediately after resection, as well as in 4- month follow-ups. The immunohistological diagnosis proved to be a PTH positive parathyroid adenoma. LESSONS In case of hypercalcemia, serum intact PTH and parathyroid imaging should be monitored to evaluate the presence of parathyroid adenoma with care because PHPT could present with inappropriate normal PTH.
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Affiliation(s)
- Can Pang
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Clinical Center for Diabetes, Shanghai Clinical Center for Metabolic Diseases, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Diabetes Institute
| | - Youben Fan
- Department of General Surgery, Center of Thyroid and Parathyroid, Shanghai Jiao Tong University Affiliated Sixth People's Hospital
| | - Huizheng Zhang
- Department of Pathology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Haoyong Yu
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Clinical Center for Diabetes, Shanghai Clinical Center for Metabolic Diseases, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Diabetes Institute
| | - Bomin Guo
- Department of General Surgery, Center of Thyroid and Parathyroid, Shanghai Jiao Tong University Affiliated Sixth People's Hospital
| | - Jie Kang
- Department of General Surgery, Center of Thyroid and Parathyroid, Shanghai Jiao Tong University Affiliated Sixth People's Hospital
| | - Xianzhao Deng
- Department of General Surgery, Center of Thyroid and Parathyroid, Shanghai Jiao Tong University Affiliated Sixth People's Hospital
| | - Yuqian Bao
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Clinical Center for Diabetes, Shanghai Clinical Center for Metabolic Diseases, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Diabetes Institute
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Surgery for Primary Hyperparathyroidism with Normal Non-suppressed Parathyroid Hormone can be Both Challenging and Successful. World J Surg 2017; 42:409-414. [DOI: 10.1007/s00268-017-4323-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sadeghi N, Li NW, Shokri T, Akin E, Joshi AS, Knoll S. Minimally elevated preoperative parathyroid hormone level influences the management of primary hyperparathyroidism. Laryngoscope 2017; 128:1016-1021. [PMID: 28850730 DOI: 10.1002/lary.26699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/05/2017] [Accepted: 04/25/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine the effect of preoperative parathyroid hormone (PTH) level on the extent of surgery and the accuracy of parathyroid imaging in primary hyperparathyroidism. STUDY DESIGN Retrospective cohort. METHODS Final diagnosis of single-gland adenoma and its location versus multigland disease was established in this retrospective cohort study. Positive predictive value, negative predictive value, and accuracy of imaging were analyzed in relation to preoperative PTH levels. RESULTS Eighty-seven percent of the 218 patients enrolled in the study underwent unilateral targeted operation and had a 97.9% (95% confidence interval: 95.8%-100%) success rate. However, in patients with PTH <65 pg/mL, 28.6% had bilateral exploration compared to 10.3% in those with PTH ≥65 pg/mL (P = .042). In patients with PTH <65 pg/mL, 7/21 (33.3%) had inaccurate sestamibi findings compared to 24/174 (13.8%) in patients with PTH ≥65 pg/mL (P = .047). CONCLUSIONS Accuracy of sestamibi drops significantly, by threefold, in patients with mild primary hyperparathyroidism and PTH <65 pg/mL. Patients with PTH < 65 pg/mL have a 2.5-fold higher rate of bilateral operation to identify the hypersecreting gland(s) compared to patients with PTH ≥65 pg/mL. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1016-1021, 2018.
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Affiliation(s)
- Nader Sadeghi
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Ning-Wei Li
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Tom Shokri
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Esma Akin
- Division of General Surgery, Department of Surgery, George Washington University, Washington, DC, U.S.A
| | - Arjun S Joshi
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Stanley Knoll
- Department of Radiology, George Washington University, Washington, DC, U.S.A
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Abstract
The biochemical profile of classic primary hyperparathyroidism (pHPT) consists of both elevated calcium and parathyroid hormone levels. The standard of care is parathyroidectomy unless prohibited by medical comorbidities. Because more patients are undergoing routine bone density evaluation and neck imaging studies for other purposes, there is a subset of people identified with a biochemically mild form of the pHPT that expresses itself as either elevated calcium or parathyroid hormone levels. These patients often do not fall into the criteria for operation based on the National Institutes of Health consensus guidelines, and they can present a challenge of diagnosis and management. The purpose of this paper is to review the available literature on mild pHPT in an effort to better characterize this patient population and to determine whether patients benefit from parathyroidectomy. Evidence suggests that there are patients with mild pHPT who have overt symptoms that are found to improve after parathyroidectomy. There is also a group of patients with biochemically mild pHPT who are found to progress to classic pHPT over time; however, it is not predictable which group of patients this will be. Early intervention for this group with mild pHPT may prevent progression of bone, psychiatric, and renal complications, and parathyroidectomy has proven safe in appropriately selected patients at high volume centers.
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Affiliation(s)
- Megan K Applewhite
- Department of General Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA; Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - David F Schneider
- Department of General Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA; Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Schneider DF, Burke JF, Ojomo KA, Clark N, Mazeh H, Sippel RS, Chen H. Multigland disease and slower decline in intraoperative PTH characterize mild primary hyperparathyroidism. Ann Surg Oncol 2013; 20:4205-11. [PMID: 23943034 DOI: 10.1245/s10434-013-3190-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many patients with primary hyperparathyroidism (PHPT) present with less severe biochemical parameters. The purpose of this study was to compare the presentation, operative findings, and outcomes of these patients with "mild" PHPT to patients with "overt" disease. METHODS A retrospective review of a prospectively collected parathyroid database was performed to identify cases of PHPT undergoing an initial neck operation. Patients were classified as mild when either the preoperative calcium or PTH was within the normal limits. Comparisons were made with the Student's t test, Chi-squared test, or Wilcoxon rank-sum test where appropriate. Kaplan-Meier estimates were plotted for disease-free survival and compared by the log-rank test. RESULTS Of the 1,429 patients who met inclusion criteria, 1,049 were classified as overt and 388 (27.1 %) were mild. Within the mild group, 122 (31.4 %) presented with normocalcemic PHPT and 266 (68.6 %) had a normal PTH. The two groups had similar demographics and renal function. Interestingly, the mild group had more than double the rate of kidney stones (3.1 vs. 1.3 %, p = 0.02). The mild group was less likely to localize on sestamibi scan (62.4 vs. 78.7 %, p < 0.01). Intraoperatively, more mild patients exhibited multigland disease (34.3 vs. 14.1 %, p < 0.01). When examining intraoperative PTH (IoPTH) kinetics where single adenomas were excised, the IoPTH fell at a rate of 6.9 pg/min in mild patients compared with 11.5 pg/min in the overt group (p < 0.01). Accordingly, 62.2 % of patients in the overt group and 53.3 % in the mild group were cured at 5 min postexcision (p < 0.01). There was no difference in the rates of persistence or recurrence between the groups, and disease-free survival estimates were identical (p = 0.27). CONCLUSIONS Patients with mild PHPT were more likely to have multigland disease and a slower decline in IoPTH, but these patients can be successfully treated with surgery.
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Affiliation(s)
- David F Schneider
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, K3/704 Clinical Science Center, Madison, WI, USA,
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Yu N, Leese GP, Donnan PT. What predicts adverse outcomes in untreated primary hyperparathyroidism? The Parathyroid Epidemiology and Audit Research Study (PEARS). Clin Endocrinol (Oxf) 2013; 79:27-34. [PMID: 23506565 DOI: 10.1111/cen.12206] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 03/08/2013] [Accepted: 03/13/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study aims to identify the best biochemical risk factors alongside other factors for predicting adverse outcomes seen in untreated primary hyperparathyroidism (PHPT). DESIGN Population-based cohort study, 1997-2006. SETTING Tayside, Scotland, UK. PATIENTS Patients with untreated diagnosed PHPT. OUTCOME MEASURES AND METHODS: Outcomes considered were all-cause mortality, fatal and nonfatal cardiovascular disease (CVD). Models were derived using survival analysis. Potential biochemical predictors tested were baseline serum calcium, parathyroid hormone (PTH), creatinine and alkaline phosphatase (ALP), and other covariates considered were gender, age at diagnosis, deprivation, previous comorbidities and bisphosphonates usage. RESULTS From 1997 to 2006, 2097 patients (mean age, 68·4 years; 69·9% women) with untreated PHPT were identified with a total follow-up of 7338 person years, in the population of Tayside, Scotland. The median baseline calcium was 2·61 mm, and PTH was 7·2 pm. PTH was the only statistically significant risk factor in all outcomes observed adjusting for other covariates. Serum creatinine and ALP predicted mortality outcomes in the short term (≤3 years), but not long term. Calcium was associated with increased risk of all-cause mortality in the short term but had no significant impact on other outcomes. CONCLUSION Baseline PTH, rather than calcium, best predicts long-term outcomes in untreated PHPT.
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Affiliation(s)
- Ning Yu
- Dundee Epidemiology and Biostatistics Unit, Division of Population Health Sciences, University of Dundee, Dundee, UK.
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18
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Wallace LB, Parikh RT, Ross LV, Mazzaglia PJ, Foley C, Shin JJ, Mitchell JC, Berber E, Siperstein AE, Milas M. The phenotype of primary hyperparathyroidism with normal parathyroid hormone levels: How low can parathyroid hormone go? Surgery 2011; 150:1102-12. [DOI: 10.1016/j.surg.2011.09.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 09/13/2011] [Indexed: 11/28/2022]
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Amin AL, Wang TS, Wade TJ, Yen TWF. Normal PTH levels in primary hyperparathyroidism: still the same disease? Ann Surg Oncol 2011; 18:3437-42. [PMID: 21537864 DOI: 10.1245/s10434-011-1744-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Indexed: 12/14/2022]
Abstract
PURPOSE Previous studies have suggested that primary hyperparathyroidism (pHPT) with only normal parathyroid hormone (PTH) levels is a milder, less symptomatic form of pHPT. This study investigates symptoms, laboratory values, imaging, and outcomes of sporadic pHPT patients with normal PTH values. METHODS We reviewed our prospectively collected database of 861 patients with sporadic pHPT who underwent parathyroidectomy between December 1999 and June 2010. Patients with only normal PTH values for 6 months before surgery were compared to a randomized control group of sporadic pHPT patients with elevated PTH, matched 1:2 for age and gender. RESULTS Fifty-eight (7%) patients had only normal PTH values within 6 months of surgery. The mean PTH was 55.1 pg/ml in the normal PTH group and 151.3 pg/ml in the control group (n=116). There was no difference in preoperative calcium values, subjective symptoms, bone health, or the frequency of single-gland disease (SGD; 88% vs. 91%) between the two groups, but the normal PTH group had higher preoperative vitamin D values (30.8 vs. 21.4 ng/ml; P<0.001), smaller adenomas (405 vs. 978 mg, P<0.001), and more frequently underwent bilateral neck exploration (57% vs. 49%). There was a trend toward lower sensitivity of preoperative imaging in the normal PTH group. CONCLUSIONS Patients with pHPT and either elevated or normal PTH levels present with similar symptoms and calcium levels. The majority of patients with normal PTH have SGD, although adenomas are smaller. This may explain why patients with normal PTH values have less sensitive imaging and more frequently require four-gland exploration.
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Affiliation(s)
- Amanda L Amin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Siilin H, Lundgren E, Mallmin H, Mellström D, Ohlsson C, Karlsson M, Orwoll E, Ljunggren Ö. Prevalence of Primary Hyperparathyroidism and Impact on Bone Mineral Density in Elderly Men: MrOs Sweden. World J Surg 2011; 35:1266-72. [DOI: 10.1007/s00268-011-1062-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Adam MA, Untch BR, Danko ME, Stinnett S, Dixit D, Koh J, Marks JR, Olson JA. Severe obesity is associated with symptomatic presentation, higher parathyroid hormone levels, and increased gland weight in primary hyperparathyroidism. J Clin Endocrinol Metab 2010; 95:4917-24. [PMID: 20685860 PMCID: PMC3205600 DOI: 10.1210/jc.2010-0666] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT A relationship between primary hyperparathyroidism (PHPT) and obesity has been observed but is incompletely understood. Furthermore, obesity has been associated with vitamin D deficiency, suggesting that the three conditions may be linked. OBJECTIVE We hypothesized that PHPT in morbidly obese patients is more severe and that the difference may be explained by vitamin D deficiency. DESIGN AND SETTING, PARTICIPANTS, AND OUTCOME MEASURES: Records of 196 patients with surgically treated PHPT and known body mass index (BMI) were examined. Patients were stratified into three BMI groups: group I (nonobese), BMI < 25 kg/m(2) (n = 54); group II (non-severely obese), BMI 25-34 kg/m(2) (n = 102); and group III (severely obese), BMI 35 kg/m(2) or greater (n = 40). RESULTS Preoperative PTH levels were higher in group ΙΙΙ compared with group Ι (181 ± 153 vs. 140 ± 80 pg/ml, p = 0.04). Group III patients had larger tumors on average compared with group I (1.8 ± 1.5 vs. 1.04 ± 1.5 g, P = 0.0002). In group III, BMI positively correlated with parathyroid tumor weight (r = 0.5, P = 0.002). Postoperative PTH was higher in group III compared with group Ι (61 ± 41 vs. 44 ± 28 pg/ml, P = 0.02). There was higher frequency of depression, musculoskeletal symptoms, weakness, and gastroesophageal reflux disease in group III patients. CONCLUSIONS BMI positively correlated with parathyroid tumor weight independent of vitamin D. Severely obese patients have larger parathyroid tumor weight, higher pre- and postoperative PTH, and greater symptoms.
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Farahnak P, Ring M, Caidahl K, Farnebo LO, Eriksson MJ, Nilsson IL. Cardiac function in mild primary hyperparathyroidism and the outcome after parathyroidectomy. Eur J Endocrinol 2010; 163:461-7. [PMID: 20562163 PMCID: PMC2921810 DOI: 10.1530/eje-10-0201] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Primary hyperparathyroidism (PHPT) is associated with cardiovascular morbidity. The extent of cardiovascular abnormalities in patients with mild-asymptomatic disease is unclear. Using sensitive echocardiographic methods, we compared cardiac structure and function in patients with mild PHPT and in healthy controls, and evaluated the changes after parathyroidectomy (PTX). METHODS In a prospective case-control design, we studied 51 PHPT patients without any cardiovascular risk factors/diseases and 51 healthy matched controls. Cardiac structure, and systolic and diastolic function were evaluated by echocardiography and Doppler tissue imaging (DTI). Blood pressure (BP) and heart rate were measured. RESULTS We observed no differences in systolic or diastolic function or in cardiac morphology between the PHPT patients and the age-matched healthy controls. The regional peak systolic myocardial velocities (S') measured with DTI decreased at all sites (P<0.05) after PTX (tricuspid annulus 14.23+/-1.85 to 13.48+/-1.79, septal 8.48+/-0.96 to 7.97+/-0.85, and lateral 9.61+/-2.05 to 8.87+/-1.63 cm/s, part of the mitral annulus). At baseline, systolic BP was higher in patients compared to controls (127.6+/-17.1 vs 119.6+/-12.6 mmHg, P<0.05). After PTX, both systolic (127.6+/-17.1 vs 124.6+/-16.6 mmHg, P<0.05) and diastolic (80.3+/-9.6 vs 78.4+/-8.6 mmHg, P<0.05) BP decreased. CONCLUSIONS Our results indicate that patients with PHPT without cardiovascular risk factors have a normal global systolic and diastolic function and cardiac morphology. BP and the systolic velocities were marginally reduced after PTX, but reflected the values of the control group. Our findings warrant further investigation of the clinical and prognostic significance of these possibly disease-related inotropic effects.
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Affiliation(s)
- P Farahnak
- Section of Surgery, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, S-118 83 Stockholm, Sweden.
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Gurrado A, Marzullo A, Lissidini G, Lippolis A, Rubini D, Lastilla G, Testini M. Substernal oxyphil parathyroid adenoma producing PTHrP with hypercalcemia and normal PTH level. World J Surg Oncol 2008; 6:24. [PMID: 18291038 PMCID: PMC2279131 DOI: 10.1186/1477-7819-6-24] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Accepted: 02/21/2008] [Indexed: 11/13/2022] Open
Abstract
Background Parathyroid adenoma is the most common cause of primary hyperparathyroidism. Preoperative serum calcium and intact-parathyroid hormone levels are the most useful diagnostic parameters that allow differentiating primary hyperparathyroidism from non-parathyroid-dependent hypercalcemia. Parathyroidectomy is the definitive treatment for primary hyperparathyroidism. Approximately 5% of patients who underwent parathyroidectomy present with persistent or recurrent hyperparathyroidism due to ectopic localization of the adenoma. Functioning oxyphil parathyroid adenoma is an uncommon histological form, seldom causing primary hyperparathyroidism. Parathyroid adenoma with hypercalcemia exhibiting normal parathyroid hormone level is rare. An incidence of 5% to 33% has been documented in the literature; no etiologic explanation has been given. In 1987, parathyroid-hormone-related peptide was isolated as a causative factor of humeral hypercalcemia of malignancy. The presence of parathyroid-hormone-related peptide in parathyroid tissue under normal and pathological conditions has been described in the literature; however, its role in causing hyperparathyroidism has not yet been defined. Case presentation We present a case of persistent hypercalcemia with a normal level of intact-parathyroid hormone due to a substernal parathyroid adenoma, treated with radioguided parathyroidectomy. The final histological diagnosis was oxyphil adenoma, positive for parathyroid-hormone-related peptide antigens. Conclusion In clinical practice, this atypical biochemical presentation of primary hyperparathyroidism should be considered in the differential diagnosis of hypercalcemia. The parathyroid-hormone-related peptide should be considered not only in the presence of malignancy.
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Affiliation(s)
- Angela Gurrado
- Department of Applications in Surgery of Innovative Technologies, University Medical School of Bari,
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Siilin H, Rastad J, Ljunggren O, Lundgren E. Disturbances of calcium homeostasis consistent with mild primary hyperparathyroidism in premenopausal women and associated morbidity. J Clin Endocrinol Metab 2008; 93:47-53. [PMID: 18042652 DOI: 10.1210/jc.2007-0600] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Primary hyperparathyroidism (PHPT) and associated morbidity are comprehensively assessed in elderly females; however, less is known of the disease in younger women. OBJECTIVES Our objectives were to estimate the prevalence of mild disturbances in calcium homeostasis, which could be analogous with early PHPT, in a premenopausal population, and determine the potential presence of associated morbidity. DESIGN Initial results from this longitudinal study are from 2002-2004. SETTING We conducted a population-based screening of serum (s)-calcium in conjunction with routine mammography. PARTICIPANTS Participants included premenopausal women, 40-50 yr of age (n = 1900). Cases fulfilling previously evaluated biochemical criteria for PHPT (n=214) were matched to controls (n = 214). MAIN OUTCOME MEASUREMENTS All participants underwent investigation, including screening of parameters of calcium homeostasis, dual x-ray absorptiometry, and body mass index assessment, and filled out extensive health and quality of life (SF-36) questionnaires. Participants were divided into four groups depending on the relation between s-calcium/intact PTH. Statistical comparisons between cases and controls as well as among the four groups were performed to evaluate morbidity. RESULTS The prevalence of assumed mild PHPT, i.e. inappropriate intact PTH value in relation to total s-calcium, was estimated to be 5.1% (n = 96). Women with mild disturbances in calcium homeostasis had statistically significant lower bone mineral density in the proximal femur and femoral neck, higher body mass index, and lower scores for vitality and general health in the analysis of SF-36. CONCLUSIONS Mild disturbances in calcium homeostasis in premenopausal women were more prevalent than previously thought and were associated with obesity, lower bone mineral density, and decreased quality of life.
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Affiliation(s)
- Helene Siilin
- Department of Surgery, University Hospital, S-751 85 Uppsala, Sweden.
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Clerici T, Brandle M, Lange J, Doherty GM, Gauger PG. Impact of intraoperative parathyroid hormone monitoring on the prediction of multiglandular parathyroid disease. World J Surg 2004; 35:336-41. [PMID: 14708048 DOI: 10.1007/s00268-010-0887-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Optimal interpretation of the results of intraoperative parathyroid hormone (IOPTH) monitoring during neck exploration for primary hyperparathyroidism (pHPT) is still controversial. The reliability of the "50% rule" in multiglandular disease (MGD) is often disputed, mostly because of competing pathophysiologic paradigms. The aim of this study was to ascertain and corroborate the ability of IOPTH monitoring to detect MGD in a practice, combining conventional and alternative parathyroidectomy techniques. This is a retrospective single institution analysis of 69 consecutive patients undergoing cervical exploration for pHPT by various approaches. The IOPTH measurements were performed after induction of anesthesia but prior to skin incision and 10 minutes after excision of the first visualized enlarged parathyroid gland. In this series, 55 patients (80%) had single adenomas, and 14 patients (20%) had MGD. In 8 of the 14 patients with MGD, IOPTH levels were obtained sequentially after removal of every enlarged gland. Of these 8 patients, 6 (75%) had a false-positive decrease (decrease below 50% of baseline value in presence of another enlarged gland) failing to predict the presence of a second enlarged gland. In 2 cases IOPTH monitoring provided a true-negative result, correctly predicting MGD. If MGD is defined by gross morphologic criteria, IOPTH monitoring fails to predict the presence of MGD reliably. However, if MGD is defined by functional criteria, the course of these patients does not seem significantly affected. The importance of these findings must be further investigated, especially with regard to the outcome of minimally invasive parathyroid procedures.
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Affiliation(s)
- Thomas Clerici
- Department of Surgery, Kantonsspital St. Gallen, CH-9007 St. Gallen, Switzerland.
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