An Approach to a Patient With Primary Hyperparathyroidism and a Suspected Ectopic Parathyroid Adenoma

Clinical and Economic Evaluation of Ultrasound-Guided Radiofrequency Ablation vs. Parathyroidectomy for Patients with Primary Hyperparathyroidism: A Cohort Study

RATIONALE AND OBJECTIVES

To compare the clinical and economic effects of ultrasound (US)-guided radiofrequency ablation (RFA) with parathyroidectomy (PTX) for primary hyperparathyroidism (PHPT).

MATERIALS AND METHODS

From April 2014 to April 2021, 123 PHPT patients who received US-guided RFA or PTX were studied. Propensity score (PS) matching was used to balance the baseline data of the two groups. The rates of cure, recurrent and persistent PHPT, and complications were compared. A Chinese healthcare system perspective cost minimization analysis was conducted.

RESULTS

After PS matching, 37 patient pairs (1:1) were created for the two groups. Follow-up was 27.2 ± 10.6 months and 28.8 ± 16.1 months for the RFA and PTX groups, respectively. At the last follow-up, there was no evidence of differences regarding clinical cure rate between the two groups (RFA vs. PTX, 91.9% vs. 94.6%, p = 1.000). Recurrent PHPT did not develop in any patient. One patient in each group had persistent PHPT. The incidence of complications and side effects, except postoperative pain (RFA vs. PTX, 16.2% vs. 40.5%, p = 0.020), were no significant difference between the two groups (all, p > 0.05). The incremental cost was -$284.00; thus, RFA was more cost-effective. For patients with employee medical insurance or resident medical insurance, the incremental costs (RFA vs. PTX) were -$391.94 and -$49.43, respectively.

CONCLUSION

There were no significant differences in efficacy and safety between RFA and PTX. As the incremental cost for RFA compared with PTX was negative, RFA may be used as a more cost-effective nonsurgical treatment alternative for PHPT.

Giant parathyroid adenoma presenting with multiple pathologic fractures: A case report

Key Clinical Message

Hyperparathyroidism is a common endocrine disorder, which must be suspected in patients presenting with fatigue, history of pathologic fracture and the diagnosis can be confirmed by elevated calcium and PTH levels, and the preferred treatment option.

Abstract

Primary hyperparathyroidism (PHPT), a common endocrine condition, with elevated parathormone production causes increased blood calcium levels. Parathyroid adenomas cause the majority of PHPT cases. Significant hypercalcemia can result from giant parathyroid adenomas. A calcium crisis may not always arise in these individuals, despite enormous parathyroid adenomas and high parathyroid hormone levels, and the masses may first be mistaken for a thyroid mass. In this article, we discuss the case of a 57-year-old Iranian man who suffered from PHPT due to a massive parathyroid adenoma and had a history of extreme fatigue and several traumatic fractures. As specialists, we should have a strong clinical suspicion of giant parathyroid adenoma as reason of hyperparathyroidism. In patients with multiple bone problems such as pain and multiple pathological fractures and elevated levels of calcium and PTH, the diagnosis of GPA must be considered and their preferred treatment is surgery.

Clinical predictors of ectopic parathyroid adenomas: experience with 421 confirmed parathyroid adenoma localizations

PURPOSE

This study was designed to evaluate whether patients with ectopic parathyroid adenoma (EPA) have clinical predictors by comparing them with other patients operated on for primary hyperparathyroidism (PHPT) with uniglandular parathyroid adenomas in other localizations.

METHODS

The data of PHPT patients who underwent parathyroidectomy in our institution were assessed retrospectively. Abnormal gland localization was confirmed by operative and pathology reports as well as normocalcemia that lasted for at least 6 months postoperatively. The relationships of biochemical and clinical findings of patients with confirmed adenoma localizations were analyzed. In order to determine independent factors that can predict EPAs, binary logistic regression was used.

RESULTS

Among 421 patients (83.4% female, mean age 49 ± 13.2 years) enrolled in the study, the most common adenoma localization was the lower left parathyroid gland (36.1%; p < 0.001). Parathyroid adenomas were more common in lower localizations compared to upper localizations and were smaller in size (p < 0.001 and p = 0.004, respectively). In univariate analysis, serum intact parathyroid hormone and calcium levels were found to be higher (p = 0.004 and p = 0.002, respectively), moderate/severe hypercalcemia was more common (p = 0.024), phosphorus levels were lower (p = 0.04), and postoperative transient hypocalcemia was more common (p = 0.013) in cases of EPAs than other localizations. There was no significant difference in adenoma size between EPAs and other classical localizations. In multivariate analysis, only a high serum calcium level was an independent predictor of EPAs (OR 2.017, 95% CI 1.142-3.564, p = 0.016). Receiver-operating characteristic curve analysis yielded an optimal cutoff value of 12.25 mg/dL for serum calcium (88% sensitivity, 63% specificity, and area under the curve: 0.861).

CONCLUSION

EPAs can cause a more biochemically distinct PHPT picture compared to parathyroid adenomas in classical localizations. A high calcium level at diagnosis may be a clinical predictor for EPAs and may affect the clinical approach and imaging technique choices. Due to the increased risk of transient hypocalcemia in patients with EPAs, caution should be exercised in postoperative follow-up. Furthermore, in the event of negative preoperative imaging, starting the parathyroid exploration from the lower left region may be a good option for the surgeon.