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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wu C, Holland M, Song Z, Wang R, Gillis A, Zmijewski P, Lindeman B, Fazendin J, Chen H. Very elevated parathyroid hormone levels in patients with primary hyperparathyroidism: Is it cancer? Am J Surg 2024; 231:140-141. [PMID: 38155074 DOI: 10.1016/j.amjsurg.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 12/30/2023]
Affiliation(s)
| | | | | | | | | | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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Leszczyńska D, Szatko A, Latocha J, Kochman M, Duchnowska M, Wójcicka A, Misiorowski W, Zgliczyníski W, Glinicki P. Persistent hypercalcaemia associated with two pathogenic variants in the CYP24A1 gene and a parathyroid adenoma-a case report and review. Front Endocrinol (Lausanne) 2024; 15:1355916. [PMID: 38665259 PMCID: PMC11043563 DOI: 10.3389/fendo.2024.1355916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction 24-Hydroxylase, encoded by the CYP24A1 gene, is a crucial enzyme involved in the catabolism of vitamin D. Loss-of-function mutations in CYP24A1 result in PTH-independent hypercalcaemia with high levels of 1,25(OH)2D3. The variety of clinical manifestations depends on age, and underlying genetic predisposition mutations can lead to fatal infantile hypercalcaemia among neonates, whereas adult symptoms are usually mild. Aim of the study We report a rare case of an adult with primary hyperparathyroidism and loss-of-function mutations in the CYP24A1 gene and a review of similar cases. Case presentation We report the case of a 58-year-old woman diagnosed initially with primary hyperparathyroidism. Preoperatively, the suspected mass adjoining the upper pole of the left lobe of the thyroid gland was found via ultrasonography and confirmed by 99mTc scintigraphy and biopsy as the parathyroid gland. The patient underwent parathyroidectomy (a histopathology report revealed parathyroid adenoma), which led to normocalcaemia. After 10 months, vitamin D supplementation was introduced due to deficiency, and the calcium level remained within the reference range. Two years later, biochemical tests showed recurrence of hypercalcaemia with suppressed parathyroid hormone levels and elevated 1,25(OH)2D3 concentrations. Further investigation excluded the most common causes of PTH-independent hypercalcaemia, such as granulomatous disease, malignancy, and vitamin D intoxication. Subsequently, vitamin D metabolites were measured using LC-MS/MS, which revealed high levels of 25(OH)D3, low levels of 24,25(OH)2D3 and elevated 25(OH)2D3/24,25(OH)2D3 ratios, suggesting a defect in vitamin D catabolism. Molecular analysis of the CYP24A1 gene using the NGS technique revealed two pathogenic variants: p.(Arg396Trp) and p.(Glu143del) (rs114368325 and rs777676129, respectively). Conclusions The diagnostic process for hypercalcaemia becomes complicated when multiple causes of hypercalcaemia coexist. The measurement of vitamin D metabolites using LC-MS/MS may help to identify carriers of CYP24A1 mutations. Subsequent molecular testing may contribute to establishing the exact frequency of pathogenic variants of the CYP24A1 gene and introducing personalized treatment.
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Affiliation(s)
- Dorota Leszczyńska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Alicja Szatko
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
- EndoLab Laboratory, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Julia Latocha
- Students’ Scientific Group Affiliated with the Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Magdalena Kochman
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Maria Duchnowska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Anna Wójcicka
- Warsaw Genomics, Warsaw, Poland
- Fundacja Wiedzieć Więcej, Warsaw, Poland
| | - Waldemar Misiorowski
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Wojciech Zgliczyníski
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Piotr Glinicki
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
- EndoLab Laboratory, Centre of Postgraduate Medical Education, Warsaw, Poland
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Krumeich LN, Santos A, Fraker DL, Kelz RR, Wachtel H. Modern Trends for Primary Hyperparathyroidism: Intervening on Less Biochemically Severe Disease. J Surg Res 2024; 296:489-496. [PMID: 38325011 DOI: 10.1016/j.jss.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 12/20/2023] [Accepted: 01/07/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is defined by autonomous parathyroid hormone secretion, which has broad physiologic effects. Parathyroidectomy is the only cure and is recommended for patients demonstrating symptomatic disease and/or end organ damage. However, there may be a benefit to intervening before the development of complications. We sought to characterize institutional trends in the biochemical and symptomatic presentation of PHPT and the associated cure and complication rates. METHODS We performed a retrospective cohort study of 1087 patients undergoing parathyroidectomy for PHPT, evaluating patients at 2-year intervals between 2002 and 2019. We identified signs and symptoms of PHPT based on the 2016 American Association of Endocrine Surgery Guidelines. Trends were evaluated with Kruskal Wallis, Chi-square tests, and Fisher's exact tests. RESULTS Patients with PHPT are presenting with lower parathyroid hormone (P = 0.0001) and calcium (P = 0.001) in the current era. Parathyroidectomy is more commonly performed for borderline guideline concordant patients with osteopenia (40.2%) and modest calciuria (median 246 mg/dL/24 h). 93.7% are cured, with no difference over time or between groups by guideline concordance. CONCLUSIONS Parathyroidectomy is increasingly performed for patients who demonstrate modest bone and renal dysfunction. Patients experience excellent cure rates and rarely experience postoperative hypocalcemia, suggesting a role for broader surgical indications.
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Affiliation(s)
- Lauren N Krumeich
- Department for Surgery, University of Michigan, Ann Arbor, Michigan; Department for Surgery, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Angelica Santos
- Department for Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Department for Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department for Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather Wachtel
- Department for Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Wang AYM, Tang TK, Yau YY, Lo WK. Impact of Parathyroidectomy Versus Oral Cinacalcet on Bone Mineral Density in Patients on Peritoneal Dialysis With Advanced Secondary Hyperparathyroidism: The PROCEED Pilot Randomized Trial. Am J Kidney Dis 2024; 83:456-466.e1. [PMID: 38040277 DOI: 10.1053/j.ajkd.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 10/21/2023] [Accepted: 10/22/2023] [Indexed: 12/03/2023]
Abstract
RATIONALE & OBJECTIVE Parathyroidectomy and calcimimetics have been used to reduce fracture risk in patients with kidney failure and advanced secondary hyperparathyroidism (SHPT), but direct comparisons of these treatment approaches have not been implemented. This pilot study compared their effects on bone mineral density (BMD) in this patient population. STUDY DESIGN A prospective pilot open-label randomized trial. SETTING & PARTICIPANTS 65 patients receiving maintenance peritoneal dialysis with advanced SHPT recruited from 2 university-affiliated hospitals in Hong Kong. INTERVENTIONS Total parathyroidectomy with forearm autografting versus oral cinacalcet treatment for 12 months. OUTCOME Prespecified secondary end points including changes in BMD z and T scores of femoral neck, lumbar spine, and distal radius 12 months after treatment initiation and also categorized as osteopenia or osteoporosis according to the World Health Organization. RESULTS Both total parathyroidectomy and cinacalcet significantly improved BMD of the lumbar spine and femoral neck over 12 months, but the total parathyroidectomy group had a greater increase than the cinacalcet-treated group (P<0.001). The proportion of study participants classified as having osteopenia/osteoporosis by femoral neck T-score fell from 78.2% to 51.7% in the total parathyroidectomy group (P<0.001) and from 65.7% to 52.0% in cinacalcet-treated group after 12 months (P=0.7). The proportion of participants with a T-score at the lumbar spine classified as osteopenia/osteoporosis fell from 53.1% to 31.0% in the total parathyroidectomy group (P=0.01) and from 59.4% to 53.8% with cinacalcet (P=0.3). No significant change was observed in BMD T or z score of the distal radius over 12 months with either intervention. LIMITATIONS Bone histology was not assessed, and the study duration was 12 months. CONCLUSIONS A large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Total parathyroidectomy increased the BMD of the lumbar spine and femoral neck and reduced osteopenia/osteoporosis more than oral cinacalcet. FUNDING Grants from academic (The University of Hong Kong Research) and not-for-profit (Hong Kong Society of Nephrology) entities. REGISTRATION Registered at Clinicaltrials.gov with study number NCT01447368. PLAIN-LANGUAGE SUMMARY It is not known whether oral cinacalcet and surgical parathyroidectomy differ in their effects on bone parameters in patients with advanced secondary hyperparathyroidism (SHPT) receiving peritoneal dialysis. This pilot randomized trial evaluated the effect of medical versus surgical therapy on bone mineral densities (BMD) as prespecified secondary study end points. The findings showed that a large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Parathyroidectomy increased the BMD of the lumbar spine and femoral neck more than cinacalcet over 12 months. Parathyroidectomy reduced the proportion of patients with osteopenia/osteoporosis at the lumbar spine and femoral neck more than cinacalcet after 12 months. Neither intervention led to an increase in the BMD of the distal radius over 12 months.
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Affiliation(s)
- Angela Yee-Moon Wang
- University Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
| | - Tak-Ka Tang
- University Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | | | - Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, Hong Kong
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Affiliation(s)
- Christopher R McHenry
- Department of Surgery MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Arboiro-Pinel R, Mahillo-Fernández I, Díaz-Curiel M. Primary Hyperparathyroidism: Assessment of the Effects of Parathyroidectomy Using Dual X-Ray Absorptiometry, Trabecular Bone Score, and Dual X-Ray Absorptiometry-Based Three-Dimensional Modeling. Endocr Pract 2024; 30:340-347. [PMID: 38184238 DOI: 10.1016/j.eprac.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
OBJECTIVE This study aimed to evaluate the bone microstructure to determine whether curative surgery of primary hyperparathyroidism produces changes in bone mineral density (BMD), trabecular bone score (TBS), and three-dimensional (3D) dual x-ray absorptiometry (DXA) parameters and whether these changes are comparable. METHODS We retrospectively studied 85 patients (60 women and 25 men, 60.4 ± 12.5 years) diagnosed with primary hyperparathyroidism and undergoing parathyroidectomy. Mean percent changes in BMD (lumbar spine [LS], femoral neck [FN], total hip [TH], and 1/3 radius), TBS and 3D-DXA parameters (trabecular volumetric BMD (vBMD), cortical vBMD, integral vBMD, cortical surface density (sBMD), and cortical thickness at TH) after surgery (12, 24, and/or 36 months) were calculated and compared, and we sought the determinants of these changes. RESULTS After parathyroidectomy, BMD presented statistically significant mean increases in LS, FN, and TH during the first 3 years after surgery (P < .001), accompanied by an improvement in all 3D-DXA parameters, but there were no significant changes in 1/3 radius BMD or TBS. Cortical sBMD, trabecular vBMD, and integral vBMD reached mean increases of similar magnitude to those of FN and TH BMD. Age and preoperative serum levels of parathyroid hormone and carboxy-terminal telopeptide of type 1 collagen were significantly associated with percent changes after surgery. CONCLUSION We found a benefit of parathyroidectomy for bone, with significant percent increases in LS, FN, and TH BMD up to the third year after surgery, and a qualitative benefit for the hip in both its trabecular and cortical compartments and bone strength.
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Affiliation(s)
- Rosa Arboiro-Pinel
- Metabolic Bone Diseases Unit, Department of Internal Medicine, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma Madrid, Madrid, Spain.
| | | | - Manuel Díaz-Curiel
- Metabolic Bone Diseases Unit, Department of Internal Medicine, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma Madrid, Madrid, Spain
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Gazivoda V, Prioli KM, Li AC, Pizzi L, Laird AM, Beninato T. Which Localizing Strategy is the Most Cost-Effective in Reoperative Primary Hyperparathyroidism? J Surg Res 2024; 296:547-555. [PMID: 38340488 DOI: 10.1016/j.jss.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 12/03/2023] [Accepted: 01/07/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION 2%-10% of patients with primary hyperparathyroidism (PHPT) who undergo parathyroidectomy develop persistent/recurrent disease. The aim of this study was to determine which preoperative localization method is most cost-effective in reoperative PHPT. METHODS Clinical decision analytic models comparing cost-effectiveness of localizing studies in reoperative PHPT were constructed using TreeAge Pro. Cost and probability assumptions were varied via Probabilistic Sensitivity Analysis (PSA) to test the robustness of the base case models. RESULTS Base case analysis of model 1 revealed ultrasound (US)-guided fine-needle aspiration with PTH assay as most cost-effective after localizing US. This was confirmed on PSA of model 1. Model 2 showed four-dimensional computed tomography (4D-CT) as most cost-effective after negative US. If not localized by US, on PSA, 4D-CT was the next most cost-effective test. CONCLUSIONS US-guided FNA with PTH is the most cost-effective confirmatory test after US localization. 4D-CT should be considered as the next best test after negative US.
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Affiliation(s)
- Victor Gazivoda
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Katherine M Prioli
- Center for Health Outcomes, Policy & Economics, Rutgers University, Piscataway, New Jersey
| | - Albert C Li
- Section of Vascular and Interventional Radiology, Department of Diagnostic Radiology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Laura Pizzi
- Center for Health Outcomes, Policy & Economics, Rutgers University, Piscataway, New Jersey
| | - Amanda M Laird
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Toni Beninato
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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Qu ML, Kang TF, Hong H. [Research progresses of near-infrared autofluorescence imaging used in surgery of parathyroid glands]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2024; 59:296-300. [PMID: 38561274 DOI: 10.3760/cma.j.cn115330-20231223-00322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- M L Qu
- Thyroid and Breast Surgery, the Sixth Affiliated Hospital of Jinan University, Dongguan 523888, China
| | - T F Kang
- Interventional Surgery, the Sixth Affiliated Hospital of Jinan University, Dongguan 523888, China
| | - H Hong
- Thyroid and Breast Surgery, the Sixth Affiliated Hospital of Jinan University, Dongguan 523888, China
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Knepprath JK, McHenry CR. How often are intrathyroidal parathyroid glands a cause of primary hyperparathyroidism, and how should they be managed? Surgery 2024; 175:794-798. [PMID: 37985315 DOI: 10.1016/j.surg.2023.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/18/2023] [Accepted: 06/18/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The purpose of our study was to determine the frequency and management of intrathyroidal parathyroid glands in patients with primary hyperparathyroidism and evaluate whether intrathyroidal parathyroid glands were more often superior or inferior glands. METHODS A retrospective review of the prospective parathyroid database was completed to determine the number of patients with primary hyperparathyroidism and an intrathyroidal parathyroid gland. Demographic data, laboratory and localization studies, operative management, pathology, and outcome were determined for patients with an intrathyroidal parathyroid gland and were compared with patients with an extrathyroidal parathyroid gland. RESULTS From 1990-2023, 808 patients were operated on for primary hyperparathyroidism; 17 (2%) patients had an intrathyroidal parathyroid gland, an adenoma in 15 (88.2%), and a hyperplastic gland in 2 (11.8%). The mean age was 53 years; 16 (94%) patients were female. Mean calcium and parathyroid hormone was 12 mg/dL and 150 pg/mL, and there were no differences from the extrathyroidal parathyroid group. Ultrasound and Sestamibi imaging were valuable in identifying an intrathyroidal parathyroid gland in 10 of 13 patients and 13 of 17 patients, respectively. Local excision was performed in 9 (53%) patients and lobectomy in 8 (47%) patients. Intraoperative parathyroid hormone was measured and predictive of cure in 12 patients. The location of intrathyroidal parathyroid glands was determined in 15 patients and was inferior in 11 (73%). All patients were cured. No patient developed recurrent disease after a median 54-month follow-up. CONCLUSION Intrathyroidal parathyroid glands are the cause of primary hyperparathyroidism in 2% of patients and are most often inferior glands. Local excision was accomplished in 53% of our patients.
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Affiliation(s)
- Jill K Knepprath
- Case Western Reserve University School of Medicine, Cleveland, OH. http://www.twitter.com/JillKnepprath
| | - Christopher R McHenry
- Case Western Reserve University School of Medicine, Cleveland, OH; Department of Surgery, MetroHealth Medical Center, Cleveland, OH.
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Jiang T, Deng E, Chai H, Weng N, He H, Zhang Z, Li D, Yue W, Peng C, Xu HX. Radiofrequency ablation for patients with recurrent or persistent secondary hyperparathyroidism after parathyroidectomy: initial experience. Endocrine 2024; 83:681-690. [PMID: 37725290 DOI: 10.1007/s12020-023-03513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Reoperation for recurrent or persistent secondary hyperparathyroidism (SHPT) after parathyroidectomy is challenging due to surgical scars and postoperative adhesions. Therefore, there is an increasing need to develop a new minimally invasive therapy. OBJECTIVE To analyze the efficacy of ultrasound (US)-guided radiofrequency ablation (RFA) in patients with recurrent or persistent SHPT after parathyroidectomy. PATIENTS AND METHODS From March 2013 to January 2022, 20 enlarged parathyroid glands in 10 patients with recurrent or persistent SHPT were treated with US-guided RFA. The levels of serum intact parathyroid hormone (iPTH), calcium (Ca), phosphorus (P), and alkaline phosphatase (ALP), as well as clinical symptoms, were compared before and after RFA. The ablation procedure-related complications were also evaluated. The target range for iPTH levels was approximately 2-9 times the upper limit of normal (130-585 pg/mL). RESULTS The mean follow-up time was 49.6 ± 34.5 months (range from 6 to101 months). The levels of serum iPTH, Ca, and P decreased significantly one day post-ablation. Six months after RFA, 70% of patients reached the targets for iPTH, and 50% of patients reached targets at the end of follow-up. Two patients underwent repeat ablation at 9 months and 6 years after RFA, respectively, due to persistently elevated iPTH levels, and both had serum iPTH concentrations in the recommended range at the recent follow-up visit. The patients' clinical symptoms significantly improved after ablation. Major complications after RFA included hoarseness (2/10) and permanent hypoparathyroidism (1/10). Severe hypocalcemia occurred in four patients (4/10) after ablation. CONCLUSION US-guided percutaneous RFA for recurrent or persistent SHPT is safe, efficacious, and repeatable, and can significantly improve hyperparathyroidism-related symptoms.
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Affiliation(s)
- Tingting Jiang
- Department of Medical Ultrasound, Center of Minimally Invasive Treatment for Tumor, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200072, China
- Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, 200072, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, 200072, China
| | - Erya Deng
- Department of Medical Ultrasound, Center of Minimally Invasive Treatment for Tumor, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200072, China
- Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, 200072, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, 200072, China
| | - Huihui Chai
- Department of Medical Ultrasound, Center of Minimally Invasive Treatment for Tumor, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200072, China
- Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, 200072, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, 200072, China
| | - Ning Weng
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, 310007, China
| | - Hongfeng He
- Department of Ultrasound, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, 310014, China
| | - Zhengxian Zhang
- Department of Ultrasound, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, 310007, China
| | - Dandan Li
- Department of Medical Ultrasound, Center of Minimally Invasive Treatment for Tumor, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200072, China
- Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, 200072, China
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, 200072, China
| | - Wenwen Yue
- Department of Medical Ultrasound, Center of Minimally Invasive Treatment for Tumor, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200072, China.
- Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, 200072, China.
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, 200072, China.
| | - Chengzhong Peng
- Department of Medical Ultrasound, Center of Minimally Invasive Treatment for Tumor, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200072, China.
- Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai, 200072, China.
- Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, 200072, China.
| | - Hui-Xiong Xu
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, 200032, China
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Affiliation(s)
- Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, 53202, USA.
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Tan J, Zhang Y, Han X, Fan Y, Xu J, Chen G, Liu C, Xu S. Microwave ablation for recurrent primary hyperparathyroidism in four patients with multiple endocrine neoplasia type 1: a case series report. Int J Hyperthermia 2024; 41:2308056. [PMID: 38314667 DOI: 10.1080/02656736.2024.2308056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/15/2024] [Indexed: 02/06/2024] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1), a rare tumor syndrome, is inherited in an autosomal dominant pattern, mainly manifested as primary hyperparathyroidism (PHPT). Surgery is preferred for patients with MEN1 and PHPT. Thermal ablation has been widely applied for PHPT but rarely for postoperative recurrent PHPT in MEN1 patients. Based on a series of cases, we aimed to investigate the clinical efficacy and safety of ultrasound-guided percutaneous microwave ablation in the treatment of MEN1 patients with postoperative recurrence of PHPT.
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Affiliation(s)
- Jie Tan
- Endocrine and Diabetes Center, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yuzhi Zhang
- Key Laboratory of Traditional Chinese Medicine (TCM) Syndrome and Treatment of Yingbing (Thyroid Disease) of State Administration of Traditional Chinese Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Xue Han
- Endocrine and Diabetes Center, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yaofu Fan
- Endocrine and Diabetes Center, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Juan Xu
- Endocrine and Diabetes Center, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Guofang Chen
- Endocrine and Diabetes Center, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Ultrasound, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Chao Liu
- Endocrine and Diabetes Center, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Ultrasound, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Shuhang Xu
- Endocrine and Diabetes Center, The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
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Santucci N, Ksiazek E, Pattou F, Baud G, Mirallié E, Frey S, Trésallet C, Sébag F, Guérin C, Mathonnet M, Christou N, Donatini G, Brunaud L, Gaujoux S, Ménégaux F, Najah H, Binquet C, Goudet P, Lifante JC. Recurrence After Surgery for Primary Hyperparathyroidism in 517 Patients With Multiple Endocrine Neoplasia Type 1: An Association Francophone de Chirurgie Endocrinienne and Groupe d'étude des Tumeurs Endocrines study. Ann Surg 2024; 279:340-345. [PMID: 37389888 DOI: 10.1097/sla.0000000000005980] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To assess recurrence according to the type of surgery for primary hyperparathyroidism (pHPT) in multiple endocrine neoplasia type 1 ( MEN1 ) patients and to identify the risk factors for recurrence after the initial surgery. BACKGROUND In MEN1 patients, pHPT is multiglandular, and the optimal extent of initial parathyroid resection influences the risk of recurrence. METHODS MEN1 patients who underwent initial surgery for pHPT between 1990 and 2019 were included. Persistence and recurrence rates after less than subtotal parathyroidectomy (LTSP) and subtotal parathyroidectomy (STP) were analyzed. Patients with total parathyroidectomy with reimplantation were excluded. RESULTS Five hundred seventeen patients underwent their first surgery for pHPT: 178 had LTSP (34.4%) and 339 STP (65.6%). The recurrence rate was significantly higher after LTSP (68.5%) than STP (45%) ( P < 0.001). The median time to recurrence after pHPT surgery was significantly shorter after LTSP than after STP: 4.25 (1.2-7.1) versus 7.2 (3.9-10.1) years ( P < 0.001). A mutation in exon 10 was an independent risk factor of recurrence after STP (odds ratio = 2.19; 95% CI: 1.31; 3.69; P = 0.003). The 5 and 10-year recurrent pHPT probabilities were significantly higher in patients after LTSP with a mutation in exon 10 (37% and 79% vs 30% and 61%; P = 0.016). CONCLUSIONS Persistence, recurrence of pHPT, and reoperation rate are significantly lower after STP than LTSP in MEN1 patients. Genotype seems to be associated with the recurrence of pHPT. A mutation in exon 10 is an independent risk factor for recurrence after STP, and LTSP may not be recommended when exon 10 is mutated.
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Affiliation(s)
- Nicolas Santucci
- Department of Digestive and Endocrine Surgery, Dijon University Hospital
- INSERM, University de Bourgogne-Franche-Comté, UMR1231, EPICAD Team "Lipids, Nutrition, Cancer"
| | | | - François Pattou
- Department of General and Endocrine Surgery, University Hospital, Lille, INSERM U1190, Lille
| | - Gregory Baud
- Department of General and Endocrine Surgery, University Hospital, Lille, INSERM U1190, Lille
| | - Eric Mirallié
- Department of Oncological, Digestive and Endocrine Surgery (CCDE) Hôtel Dieu, CIC-IMAD, Nantes
| | - Samuel Frey
- Department of Oncological, Digestive and Endocrine Surgery (CCDE) Hôtel Dieu, CIC-IMAD, Nantes
| | - Christophe Trésallet
- Department of Digestive and Endocrine Surgery, Avicenne University Hospital, AP-HP Sorbonne Paris Nord University, Bobigny
| | - Frédéric Sébag
- Department of General Endocrine and Metabolic Surgery, Conception University Hospital, APHM, Aix Marseille University, Marseille
| | - Carole Guérin
- Department of General Endocrine and Metabolic Surgery, Conception University Hospital, APHM, Aix Marseille University, Marseille
| | - Muriel Mathonnet
- Department of Surgery, Dupuytren University Hospital of Limoges, Limoges
| | - Niki Christou
- Department of Surgery, Dupuytren University Hospital of Limoges, Limoges
| | - Gianluca Donatini
- Department of General and Endocrine Surgery, University Hospital of Poitiers, Poitiers
| | - Laurent Brunaud
- Department of Gastrointestinal, Metabolic, and Cancer Surgery (CVMC), University Hospital of Nancy (CHRU Nancy), INSERM NGERE U1256, University of Lorraine, Rue du Morvan
| | - Sébastien Gaujoux
- Department of Endocrine and Pancreatic Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris
| | - Fabrice Ménégaux
- Department of Endocrine and Pancreatic Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris
| | - Haythem Najah
- Department of Hepatobiliary Surgery, Bordeaux University Hospital, Bordeaux
| | - Christine Binquet
- INSERM, University de Bourgogne-Franche-Comté, UMR1231, EPICAD Team "Lipids, Nutrition, Cancer"
- INSERM, CIC1432, Clinical Epidemiology, Dijon
| | - Pierre Goudet
- Department of Digestive and Endocrine Surgery, Dijon University Hospital
| | - Jean-Christophe Lifante
- Department of Digestive and Endocrine Surgery, University Hospital of Lyon Sud and EA 7425 HESPER, Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France
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15
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Colaianni CA, Shindo M. Parathyroidectomy: An Operative Guide. Otolaryngol Clin North Am 2024; 57:117-123. [PMID: 37714781 DOI: 10.1016/j.otc.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
This guide delineates a step-by-step approach to targeted parathyroidectomy and 4 gland exploration, with embedded clinical pearls regarding anatomy, approach, and considerations.
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Affiliation(s)
| | - Maisie Shindo
- Department of Otolaryngology, Head and Neck Surgery, Head & Neck Endocrine Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland OR 97239, USA.
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16
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Tao Y, Xu C, Fang C. A commentary on " Parathyroidectomy for primary hyperparathyroidism: effect on quality of life after 3 years - a prospective cohort study". Int J Surg 2024; 110:1273-1274. [PMID: 37983786 PMCID: PMC10871652 DOI: 10.1097/js9.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/09/2023] [Indexed: 11/22/2023]
Affiliation(s)
| | | | - Chen Fang
- Department of Endocrinology
- Department of Nutrition, The Second Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
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17
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Kanin MR, Leung AM. Overview of Thyroid and Parathyroid Disease-The Endocrinology Perspective. Otolaryngol Clin North Am 2024; 57:11-24. [PMID: 37634985 DOI: 10.1016/j.otc.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Thyroid and parathyroid disorders are quite common in the population and range from benign to malignant conditions that may be hormonally active or inactive. Select disorders of the thyroid and parathyroid can be managed medically, although there are a variety of circumstances that may require definitive management with surgery. Surgical intervention may be required for hormonal control, compressive symptoms, or for the removal and/or control of malignancy. The endocrinologist's perspective of the preoperative and postoperative management regarding thyroid and parathyroid surgeries will be discussed.
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Affiliation(s)
- Maralee R Kanin
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Avenue, CHS 57-145, Los Angeles, CA 90095, USA; Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard (111D), Los Angeles CA 90073, USA
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Avenue, CHS 57-145, Los Angeles, CA 90095, USA; Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard (111D), Los Angeles CA 90073, USA.
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18
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Chou FF, Chi SY, Wu YJ, Chan YC, Huang SC. Preoperative work-up and results of parathyroidectomy plus auto-transplantation for the elderly with secondary hyperparathyroidism. Asian J Surg 2024; 47:880-885. [PMID: 37989683 DOI: 10.1016/j.asjsur.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/17/2023] [Accepted: 10/06/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Total parathyroidectomy for secondary hyperparathyroidism has low morbidity and mortality rates and requires a special workup in the preoperative period. METHODS Neck echography and technetium-99m-sestamibi scintigraphy were performed preoperatively. Cardiac echography, a thallium-201 myocardial perfusion scan, and cardiac catheterization were performed if necessary. During surgery, we removed all the parathyroid glands and the upper thymus and autotransplanted 100 mg of the smallest gland into the subcutaneous tissue of the forearm. RESULTS The success rate in three months after total parathyroidectomy was 91.7% without mortality. In the elderly (age ≤65 years, n = 35), bone pain, skin itching, general weakness, and insomnia improved three months after surgery, and grip strength increased significantly. One year after parathyroidectomy, the serum levels of Ca, P, alkaline phosphatase, and intact parathyroid hormone were all within the normal ranges. Except for the bone mineral density (BMD) of the radial distal one-third, the BMD of the lumbar spine (L2 to L4), femoral neck, femoral global, and radial global increased significantly. Furthermore, the bone density T-scores of the lumbar spine (L2 to L4), femoral neck, femoral global, radial distal one-third, and radial global improved significantly. CONCLUSIONS After a meticulous preoperative workup, parathyroidectomy plus autotransplantation can be performed safely for the treatment of symptomatic secondary hyperparathyroidism in the elderly to improve their quality of life and decrease their incidence of bone fractures.
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Affiliation(s)
- Fong-Fu Chou
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan.
| | - Shun-Yu Chi
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Yi-Ju Wu
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Yi-Chia Chan
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Shun-Chen Huang
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Taiwan
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Phillips W, Stallworth J, Gillis A, Lindeman B, Chen H, Fazendin J, Zmijewski P. Patient perspectives on barriers to obtaining surgery for primary hyperparathyroidism: A qualitative review. Am J Surg 2024; 228:122-125. [PMID: 37640639 DOI: 10.1016/j.amjsurg.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The purpose of this study was to qualitatively explore patient-reported barriers to surgery for primary hyperparathyroidism (PHPT) and identify actionable interventions to improve access to surgical care. METHODS We recruited forty-nine patients in an endocrine surgery clinic at a large, academic medical to participate in an 11- question phone interview. All interviewees underwent parathyroidectomy for primary hyperparathyroidism. Responses were recorded and a codebook of qualitative themes, blinded to patient race and sex, was created by 3 independent reviewers. Comments were subsequently sorted into the codebook with patient demographic information. RESULTS Patients that experienced delays in parathyroidectomy most commonly cited "issues with the referral process" and "missed diagnosis" as the cause. Patients were asked to identify the most challenging part about the surgery process. Commonly evoked themes among patients of both races and sexes included "transportation" and "financial" with subthemes of "no ride," "distance from surgeon," "insurance," and "difficulty taking time off work." Patients were asked to name actionable interventions to improve access to surgical care. The most commonly evoked theme involved "support systems," with subthemes of "transportation assistance," "financial," and "patient advocacy." Physician factors were also commonly evoked among patients of both races with subthemes of "knowledge", "communication," and "listening." CONCLUSION PHPT patients cited multiple barriers to undergoing surgery. Future work can focus on examining these questions with a larger patient cohort and examining delays at the referral and diagnosis stage, which was most commonly cited by our respondents.
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Affiliation(s)
- Walker Phillips
- Department of Surgery, The University of Alabama at Birmingham, USA
| | - James Stallworth
- Department of Surgery, The University of Alabama at Birmingham, USA
| | - Andrea Gillis
- Department of Surgery, The University of Alabama at Birmingham, USA
| | | | - Herbert Chen
- Department of Surgery, The University of Alabama at Birmingham, USA
| | - Jessica Fazendin
- Department of Surgery, The University of Alabama at Birmingham, USA
| | - Polina Zmijewski
- Department of Surgery, The University of Alabama at Birmingham, USA.
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Salimkhanov R, Bondarenko E, Eremkina A, Bibik E, Kim E, Begova K, Kim I, Kuznetsov S, Mokrysheva N. Case report: Sagliker syndrome in the patient with recurrent tertiary hyperparathyroidism due to intrathyroidal parathyroid carcinoma. Front Endocrinol (Lausanne) 2024; 14:1292993. [PMID: 38250739 PMCID: PMC10796468 DOI: 10.3389/fendo.2023.1292993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Sagliker syndrome (SS) is an extremely rare disorder that manifests in patients with advanced chronic kidney disease (CKD) undergoing programmed hemodialysis as a renal replacement therapy. Treatment of secondary hyperparathyroidism (SHPT) in these patients is still challenging. The main clinical manifestations of SS include craniofacial and fingertip deformities, dental anomalies, gingival hyperplasia, short stature, hearing loss, neurological and psychiatric impairment. The etiology and pathogenesis of SS in patients with SHPT require further clarification. However, mutations in the GNAS1, FGF23, and FGFR3 genes were described in some patients, suggesting a possible role of genetic predisposition to the syndrome. The preferred therapeutic approach for SS is surgery, but the volume of the operation is debated. The main surgical strategies include total, subtotal parathyroidectomy, or total parathyroidectomy with autotransplantation of the parathyroid gland (PG). Unfortunately, parathyroidectomy does not contribute to the regression of significant skeletal deformities. We present a unique clinical case of a patient with classical features of SS, recurrent tertiary hyperparathyroidism (THPT) after total parathyroidectomy due to intrathyroidal parathyroid carcinoma (PC).
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Affiliation(s)
- Rustam Salimkhanov
- Department of Parathyroid Pathology and Mineral Disorders, Endocrinology Research Center, Moscow, Russia
| | | | - Anna Eremkina
- Department of Parathyroid Pathology and Mineral Disorders, Endocrinology Research Center, Moscow, Russia
| | - Ekaterina Bibik
- Department of Parathyroid Pathology and Mineral Disorders, Endocrinology Research Center, Moscow, Russia
| | - Ekaterina Kim
- Department of Parathyroid Pathology and Mineral Disorders, Endocrinology Research Center, Moscow, Russia
| | - Kamila Begova
- Department of Parathyroid Pathology and Mineral Disorders, Endocrinology Research Center, Moscow, Russia
| | - Ilya Kim
- Department of Endocrine Surgery, Endocrinology Research Center, Moscow, Russia
| | - Sergey Kuznetsov
- Department of Endocrine Surgery, Endocrinology Research Center, Moscow, Russia
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21
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Cao R, Jiang H, Liang G, Zhang W. Dynamic nomogram for predicting hungry bone syndrome before parathyroidectomy. Endocrine 2024; 83:196-204. [PMID: 37640988 DOI: 10.1007/s12020-023-03493-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE The objective of this study was to develop a dependable and uncomplicated prediction model utilizing clinical information readily accessible to patients before surgery. This model aimed to assess the likelihood of hungry bone syndrome occurrence in post-surgery patients with secondary hyperparathyroidism (SHPT), and to assist clinicians in adjusting treatment plans promptly. METHODS In this study, we constructed an online nomogram utilizing independent variables determined through multiple logistic regression to predict the probability of HBS occurrence after parathyroidectomy in patients with secondary hyperparathyroidism. To evaluate the precision and dependability of the nomogram, we used receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). RESULTS Multivariate logistic regression analyses on 136 eligible patients identified age, parathyroid hormone (PTH), and blood calcium as independent HBS risk factors, which were then integrated into the nomogram. The area under ROC curve demonstrated the nomogram's strong predictive accuracy. The calibration curve demonstrates consistency between the model's prediction probability and observed probability, reflecting high prediction accuracy of the nomogram. Dynamic nomograms were found to hold significant practical clinical value as demonstrated by clinical decision analysis. It can be accessed on https://min115.shinyapps.io/dynnomapp/ . CONCLUSION In patients with secondary hyperparathyroidism, the dynamic nomogram based on age, parathyroid hormone, and blood calcium can more accurately predict the likelihood of HBS after parathyroidectomy, allowing doctors to make clinical decisions more quickly and adjust treatment plans in a timely manner to reduce the incidence of HBS.
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Affiliation(s)
- Runmin Cao
- Jinzhou Medical University Postgraduate Training Base (Jinzhou Central Hospital), Jinzhou City, Liaoning Province, China
| | - Honghe Jiang
- Anhui University of Science and Technology, Huainan City, Anhui Province, China
| | - Guangpeng Liang
- Jinzhou Medical University Postgraduate Training Base (Jinzhou Central Hospital), Jinzhou City, Liaoning Province, China
| | - Weibin Zhang
- Jinzhou Medical University Postgraduate Training Base (Jinzhou Central Hospital), Jinzhou City, Liaoning Province, China.
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22
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Baugh KA, Liu JB, Yip L, McCoy KL, Carty SE, Ramonell KM. Sex differences in patients with primary hyperparathyroidism. Surgery 2024; 175:65-72. [PMID: 37980200 DOI: 10.1016/j.surg.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/27/2023] [Accepted: 07/18/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Differences in presenting symptoms of primary hyperparathyroidism and outcomes of parathyroidectomy between sexes have been described, but whether these can be assessed by perioperative use of a validated tool, such as the Pasieka Parathyroidectomy Assessment Score, is unknown. METHOD All patients with primary hyperparathyroidism were asked to complete symptom assessment at the preoperative and postoperative visits. The assessment included a query for 13 Pasieka Parathyroidectomy Assessment Score parameters evaluated using a visual analog scale as described by Pasieka (summative score 0-1,300), and general quality of life and wellness. A review of a prospectively maintained database of primary hyperparathyroidism patients (January 2016-December 2019) was performed, and those who had a 6-month cure after initial parathyroidectomy were included. RESULTS The study cohort was mostly women (77%, 541/701). The median preoperative Pasieka Parathyroidectomy Assessment Score was higher in women (155, 0-1,190) than in men (80.5, 0-855, P < .001), although there were similar rates of asymptomatic primary hyperparathyroidism (Pasieka Parathyroidectomy Assessment Score = 0, 12.5% vs 7%, P = .042). After curative parathyroidectomy, women reported a substantial reduction in symptomatology, with Pasieka Parathyroidectomy Assessment Score declining by 35% at initial postoperative visit (median, 155 vs 100, P < .001), further decreasing to 48% by 6 months (155 vs 80, P < .001). The Pasieka Parathyroidectomy Assessment Score in men did change but to a much smaller degree at both the initial postoperative visit (80.5 vs 70; P = .036) and at 6 months (80.5 vs 57.5; P = .048). CONCLUSION When assessed with the Pasieka Parathyroidectomy Assessment Score, improvement in symptoms was clearly demonstrated for women after curative parathyroidectomy. Whether symptom improvement also occurs in men is less apparent but may be due to disparities in the development and validation of outcomes tools in general.
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Affiliation(s)
| | - Jason B Liu
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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23
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Frey S, Guillot P, Wargny M, Gérard M, Bigot-Corbel E, Bach-Ngohou K, Caillard C, Cariou B, Mirallié E, Blanchard C. Do men improve their bone mineral density 1 year after parathyroidectomy for primary hyperparathyroidism? Results of a prospective study. Surgery 2024; 175:172-179. [PMID: 37935599 DOI: 10.1016/j.surg.2023.04.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/09/2023] [Accepted: 04/27/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND The impact of parathyroidectomy on bone mineral density in men with primary hyperparathyroidism is poorly known. This study aimed to evaluate the bone mineral density and bone remodeling biomarker changes in men with primary hyperparathyroidism 1 year after parathyroidectomy. METHODS Men operated for sporadic primary hyperparathyroidism between 2016 and 2022, enrolled in a monocentric prospective cohort, were analyzed. Patients with follow-up <1 year or missing data were excluded. Bone mineral density (dual X-ray absorptiometry) was measured before and 12 months after parathyroidectomy. Bone mineral density change ≥0.03g/cm2 was deemed significant. Bone remodeling biomarkers were serum cross-linked C-telopeptide, procollagen type 1 N-terminal propeptide, and bone-specific alkaline phosphatases. RESULTS Forty-five men were included (mean age 58.8 ± 13.1 years). Before surgery, 49% had osteopenia, and 11% had osteoporosis. Mean serum calcium and median serum parathyroid hormone levels decreased significantly after surgery (P < .0001). One year after parathyroidectomy, the mean bone mineral density increased significantly at the lumbar spine (+0.04g/cm2 [0.01;0.70], P = .0054), femoral neck (+0.04g/cm2 [0.03;0.05], P < .0001) and total hip (+0.02g/cm2 [0.01;0.03], P = .0002). Considering significant bone mineral density gain (+1 point) and loss (-1 point) at each site, 29/45 patients (64% [95% CI 49;78]) improved. Bone remodeling biomarker concentrations significantly decreased (P < .001). CONCLUSION Parathyroidectomy positively affects bone mineral density in men with primary hyperparathyroidism, supporting osteopenia as a surgical indication in these patients.
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Affiliation(s)
- Samuel Frey
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France. https://twitter.com/samuelfrey13
| | - Pascale Guillot
- Nantes Université, CHU Nantes, Service de Rhumatologie, Nantes, France
| | - Matthieu Wargny
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France; Nantes Université, CHU Nantes, Pôle Hospitalo-Universitaire 11 : Santé Publique, Clinique des données, INSERM, CIC 1413, Nantes, France
| | - Maxime Gérard
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Nantes, France
| | - Edith Bigot-Corbel
- Nantes Université, CHU Nantes, Laboratoire de biochimie, Hôpital Guillaume et René Laennec, Nantes, France
| | - Kalyane Bach-Ngohou
- Nantes Université, CHU Nantes, Department of Biochemistry and INSERM, The enteric nervous system in gut and brain disorders, IMAD, F-4400 Nantes, France
| | - Cécile Caillard
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Nantes, France
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Eric Mirallié
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Nantes, France
| | - Claire Blanchard
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France.
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24
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Polkin VV, Isaev PA, Severskaya NV, Ivanov SA, Kaprin AD. [Indocyanine green angiography in assessment of parathyroid remnant perfusion after subtotal parathyroidectomy: a case report]. Khirurgiia (Mosk) 2024:61-66. [PMID: 38380466 DOI: 10.17116/hirurgia202402261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
A 72-year-old female patient with chronic kidney disease stage presented with multiple parathyroid adenomas and tertiary hyperparathyroidism. SPECT/CT with 99mTc-MIBI revealed accumulation of radiopharmaceuticals in 2 out of 4 parathyroid glands. Ultrasound established localization of all parathyroid glands. Subtotal parathyroidectomy with excision of 3 glands and resection of half of the fourth gland was performed. Intraoperative indocyanine green angiography was performed to identify all parathyroid glands and remnant perfusion. There was normal parathyroid function after 6 months.
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Affiliation(s)
- V V Polkin
- Tsyb Medical Research Radiology Center, Obninsk, Russia
| | - P A Isaev
- Tsyb Medical Research Radiology Center, Obninsk, Russia
| | | | - S A Ivanov
- Tsyb Medical Research Radiology Center, Obninsk, Russia
- People's Friendship University of Russia, Moscow, Russia
| | - A D Kaprin
- National Medical Research Radiology Centre, Obninsk, Russia
- People's Friendship University of Russia, Moscow, Russia
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25
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Milat F, Ramchand SK, Herath M, Gundara J, Harper S, Farrell S, Girgis CM, Clifton-Bligh R, Schneider HG, De Sousa SMC, Gill AJ, Serpell J, Taubman K, Christie J, Carroll RW, Miller JA, Grossmann M. Primary hyperparathyroidism in adults-(Part I) assessment and medical management: Position statement of the endocrine society of Australia, the Australian & New Zealand endocrine surgeons, and the Australian & New Zealand bone and mineral society. Clin Endocrinol (Oxf) 2024; 100:3-18. [PMID: 34931708 DOI: 10.1111/cen.14659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/30/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To formulate clinical consensus recommendations on the presentation, assessment, and management of primary hyperparathyroidism (PHPT) in adults. METHODS Representatives from relevant Australian and New Zealand Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing nine key questions. RESULTS PHPT is a biochemical diagnosis. Serum calcium should be measured in patients with suggestive symptoms, reduced bone mineral density or minimal trauma fractures, and in those with renal stones. Other indications are detailed in the manuscript. In patients with hypercalcaemia, intact parathyroid hormone, 25-hydroxy vitamin D, phosphate, and renal function should be measured. In established PHPT, assessment of bone mineral density, vertebral fractures, urinary tract calculi/nephrocalcinosis and quantification of urinary calcium excretion is warranted. Parathyroidectomy is the only definitive treatment and is warranted for all symptomatic patients and should be considered for asymptomatic patients without contraindications to surgery and with >10 years life expectancy. In patients who do not undergo surgery, we recommend annual evaluation for disease progression. Where the diagnosis is not clear or the risk-benefit ratio is not obvious, multidisciplinary discussion and formulation of a consensus management plan is appropriate. Genetic testing for familial hyperparathyroidism is recommended in selected patients. CONCLUSIONS These clinical consensus recommendations were developed to provide clinicians with contemporary guidance on the assessment and management of PHPT in adults. It is anticipated that improved health outcomes for individuals and the population will be achieved at a decreased cost to the community.
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Affiliation(s)
- Frances Milat
- Department of Endocrinology, Monash Health, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, Monash University, Victoria, Australia
| | - Sabashini K Ramchand
- Department of Endocrinology, Austin Health, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Victoria, Australia
| | - Madhuni Herath
- Department of Endocrinology, Monash Health, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, Monash University, Victoria, Australia
| | - Justin Gundara
- Department of Surgery, Redland Hospital, Metro South and Faculty of Medicine, University of Queensland, Australia
- Department of Surgery, Logan Hospital, Metro South and School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Simon Harper
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
- Department of Surgery, University of Otago, Wellington, New Zealand
| | - Stephen Farrell
- Department of Surgery, St Vincent's Hospital, Victoria, Australia
- Department of Surgery, Austin Hospital, Victoria, Australia
- Department of Surgery, Royal Children's Hospital, Victoria, Australia
- Department of Surgery, University of Melbourne, Victoria, Australia
| | - Christian M Girgis
- Department of Diabetes and Endocrinology, Westmead Hospital, New South Wales, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Kolling Institute, University of Sydney, New South Wales, Australia
| | - Hans G Schneider
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Victoria, Australia
| | - Sunita M C De Sousa
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, South Australia, Australia
| | - Anthony J Gill
- Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Jonathan Serpell
- Department of General Surgery, The Alfred Hospital, Victoria, Australia
- Monash University Department of Endocrine Surgery, Victoria, Australia
| | - Kim Taubman
- Department of Medical Imaging, St Vincent's Hospital, Victoria, Australia
- Department of Endocrinology, St Vincent's Hospital, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | | | - Richard W Carroll
- Endocrine, Diabetes, and Research Centre, Wellington Regional Hospital, Wellington, New Zealand
| | - Julie A Miller
- Department of Surgery, University of Melbourne, Victoria, Australia
- Department of Surgery, The Royal Melbourne Hospital, Victoria, Australia
- Epworth Hospital Network, Victoria, Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Victoria, Australia
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26
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Kumar A, Pandey JK, Mahto M. From Causatum to Erratum, all in a name. Clin Lab 2024; 70. [PMID: 38213205 DOI: 10.7754/clin.lab.2023.230702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND This study highlights how a trivial mistake in collecting timed blood samples of parathyroid hormone (PTH) during parathyroidectomy (PTX) can potentially become a serious error affecting surgical closure. METHODS For the measurement of serum PTH, the intact PTH (iPTH) test was used to obtain baseline, preoperative, intraoperative, and postoperative samples of PTH, to guide the surgical team regarding adequacy of PTX. RESULTS Due to the lack of proper guidelines, all types of samples for PTH are labeled as iPTH by the Laboratory Information Services (LIS) software. Due to a human error in marking the PTH vacutainers generated for different time point samples by LIS, samples were swapped. The values in the lab revealed a spurious rise in PTH post-PTX. The laboratory physician carefully observed the tubes and identified the reason for this mistake. The timely action therefore led to surgical closure, otherwise it could have led to unwarranted extended PTX. CONCLUSIONS In cases where timed samples are mandatory, having a common code for all requisitions can invariably lead to pre-analytical error, therefore proper discriminative measures need to be introduced to avoid these mistakes.
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Baugh KA, McCoy KL, Leung JH, Carty SE, Ramonell KM, Yip L. Normocalcemic hyperparathyroidism: Intervention to differentiate primary from secondary hyperparathyroidism. Surgery 2024; 175:166-171. [PMID: 37981554 DOI: 10.1016/j.surg.2023.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/05/2023] [Accepted: 06/20/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Normocalcemic hyperparathyroidism can occur, but surgery should not be considered until common etiologies for secondary hyperparathyroidism are comprehensively excluded. Calcium deficiency is an underrecognized cause of normocalcemic parathyroid hormone elevation, and we aim to determine if the implementation of a preoperative calcium challenge can be used to reduce unnecessary parathyroidectomy. METHODS Consecutive patients referred for parathyroidectomy (1/21-6/22) with normocalcemia (serum calcium <10 mg/dL) and concurrently elevated parathyroid hormone levels were routinely treated with supplemental calcium and vitamin D3, and follow-up laboratory studies were assessed. RESULTS A total of 29/314 (9%) patients had normocalcemic parathyroid hormone elevation with mean calcium, parathyroid hormone, and vitamin D 25OH levels of 9.5 ± 0.3 mg/dL, 109.9 ± 34.9 pg/mL, and 42.7 ± 23.8 ng/mL respectively. Confounding factors included estimated glomerular filtration rate <60 in 2, loop diuretic use in 4, and prior gastric bypass or gastric sleeve surgery in 4. Follow-up biochemical evaluation was available in 27 (92%); results were unchanged in 7 patients (26%); normalization of parathyroid hormone levels with persistently normal calcium levels occurred in 15 (55%), thus confirming secondary hyperparathyroidism and hypercalcemia with elevated parathyroid hormone levels (classic primary hyperparathyroidism) was diagnosed in 5 (19%). Parathyroid exploration has been completed for 3 of 5 patients with classic primary hyperparathyroidism to date. CONCLUSION A preoperative calcium challenge was prospectively initiated in normocalcemic patients with parathyroid hormone elevation, and there was high compliance (92%). Short-interval calcium supplementation revealed ∼50% to have resolved secondary hyperparathyroidism due to insufficient calcium intake, which avoided unnecessary surgery. In contrast, classic patients were unveiled in 20%, allowing for prompt and correct surgical intervention.
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Affiliation(s)
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Janet H Leung
- Department of Endocrinology, University of Pittsburgh, Pittsburgh, PA
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Ramírez Stieben LA, Pustilnik E, Néstor Rodolfo F, Bolzán D, Bedini I. Celiac disease and primary hyperparathyroidism. Rev Fac Cien Med Univ Nac Cordoba 2023; 80:499-509. [PMID: 38150201 PMCID: PMC10851394 DOI: 10.31053/1853.0605.v80.n4.42137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/13/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVE Primary hyperparathyroidism (PHPT) and celiac disease (CD) are two distinct medical conditions that can affect bone health. While PHPT leads to excessive calcium levels and bone abnormalities, CD impairs calcium and vitamin D absorption due to small intestine damage. CASE REPORT We present a case of a 49-year-old woman diagnosed with osteoporosis who was found to have both PHPT and CD. The patient underwent a successful minimally invasive parathyroidectomy, which resulted in decreased parathyroid hormone levels. CONCLUSION This case highlights the rare coexistence of PHPT and CD and emphasizes the importance of considering secondary causes of osteoporosis in patients with low bone mass. Further studies are needed to explore the underlying mechanisms and potential links between PHPT and CD.
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Affiliation(s)
| | | | | | | | - Iván Bedini
- Unidad de Tiroides y Paratiroides del Grupo Gamma.
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29
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Thumerel M, Belaroussi Y, McSweeney J, Haissaguerre M. Parathyroid adenoma in the sternocleidomastoid muscle 30years after thyroidectomy. Ann Endocrinol (Paris) 2023; 84:764-766. [PMID: 37858754 DOI: 10.1016/j.ando.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Matthieu Thumerel
- Thoracic Surgery Department, Haut Lévêque Hospital, Bordeaux University Hospital and Bordeaux University, avenue de Magellan, 33604 Pessac, Bordeaux, France.
| | - Yaniss Belaroussi
- Thoracic Surgery Department, Haut Lévêque Hospital, Bordeaux University Hospital and Bordeaux University, avenue de Magellan, 33604 Pessac, Bordeaux, France
| | - Jared McSweeney
- Thoracic Surgery Department, Haut Lévêque Hospital, Bordeaux University Hospital and Bordeaux University, avenue de Magellan, 33604 Pessac, Bordeaux, France
| | - Magalie Haissaguerre
- Endocrinology and Endocrine Oncology Department, Haut Lévêque Hospital, Bordeaux University Hospital and Bordeaux University, avenue de Magellan 33604 Pessac, Bordeaux, France
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30
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Li X, Gu H, Wu X. A commentary on 'The role of rapid intraoperative parathyroid hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis'. Int J Surg 2023; 109:4380-4381. [PMID: 37702567 PMCID: PMC10720845 DOI: 10.1097/js9.0000000000000716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Xin Li
- Department of Internal Medicine, Yuyao Hospital of Traditional Chinese Medicine
| | - Hongping Gu
- Department of Internal Medicine, Yuyao Hospital of Traditional Chinese Medicine
| | - Xiaolin Wu
- Department of Oncology, Shaoxing Shangyu People’s Hospital, Zhejiang, People’s Republic of China
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31
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Grant RRC, Moroz BE, Nilubol C, Cahoon EK, Pfeiffer RM, Nilubol N. Parathyroidectomy and the Risk of Major Cerebrovascular and Cardiovascular Events in the Elderly. Ann Surg 2023; 278:1032-1037. [PMID: 37450696 PMCID: PMC10792119 DOI: 10.1097/sla.0000000000005999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE We aimed to determine the incidence of major cardiovascular and cerebrovascular events in elderly patients with primary hyperparathyroidism (pHPT) and the impact of parathyroidectomy. SUMMARY BACKGROUND DATA pHPT is underdiagnosed and undertreated in the United States. It is associated with increased cardiovascular disease risk, but its association with cerebrovascular disease risk is not well-established. It is also unknown if parathyroidectomy reduces these risks. METHODS The incidence of major cerebrovascular and cardiovascular events in 108,869 patients with pHPT diagnosed in the Medicare database between 2008 and 2018 and a matched comparison group of 1,088,690 Medicare subjects was prospectively evaluated. We estimated hazard ratios (HR) for the association of pHPT and parathyroidectomy for the risk of these outcomes from Cox proportional hazards models. Survival curves were calculated to obtain 5-year disease-free survival estimates. RESULTS For patients with pHPT, five-year disease-free survival was lower, and HRs were higher than the comparison group for any outcome (75.9% vs. 78.4; HR 1.11, 95% confidence interval [CI] 1.09-1.13), major cerebrovascular events (84.5% vs. 86.3%; HR 1.14, 95% CI 1.12-1.17), and major cardiovascular events (87.7% vs. 88.8%; HR 1.06, 95% CI 1.03-1.08). However, in patients who had parathyroidectomy, the risks of major cerebrovascular and cardiovascular events did not differ from the comparison cohort. The lower risk in patients who had parathyroidectomy was maintained in subgroup analyses. CONCLUSIONS Older patients with pHPT have an increased risk of major cerebrovascular and cardiovascular events compared with patients without the disease. Physicians treating older patients with primary hyperparathyroidism should consider parathyroidectomy.R.M.P. and N.N. contributed equally to the preparation of this manuscript.
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Affiliation(s)
- Robert R C Grant
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Brian E Moroz
- Computing and Software Solutions for Science, LLC, Bethany Beach, DE
| | - Chanigan Nilubol
- Division of Nephrology and Hypertension, Department of Medicine, Medstar Georgetown University Medical Center, Washington, DC
| | - Elizabeth K Cahoon
- Division of Cancer Epidemiology and Genetics, Biostatistics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, Biostatistics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
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García Pascual L, Simó-Servat A, Puig-Jové C, García-González L. Normocalcemic hyperparathyroidism after successful parathyroidectomy for single parathyroid adenoma: Prevalence, etiological factors, predictive markers, treatment and evolution. ENDOCRINOL DIAB NUTR 2023; 70:640-648. [PMID: 38000970 DOI: 10.1016/j.endien.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/14/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND AND OBJECTIVE Postparathyroidectomy normocalcemic hyperparathyroidism (PPNCHPPT) is a frequent situation for which we have no information in our country. The objective is to know our prevalence of PPNCHPPT, the associated etiological factors, the predictive markers, the treatment administered and the evolution. PATIENTS AND METHOD Retrospective observational cross-sectional study on 42 patients. Twelve patients with PPNCHPPT and 30 without PPNCHPPT are compared. RESULTS HPPTNCPP prevalence: 28.6%. Etiological factors: vitamin D deficiency: 75%; bone remineralization: 16.7%; renal failure: 16.7%; hypercalciruria: 8.3%. No change in the set point of calcium-mediated parathormone (PTH) secretion was observed, but an increase in the preoperative PTH/albumin-corrected calcium (ACC) ratio was observed. Predictive markers: PTH/ACC ratio (AUC 0.947; sensitivity 100%, specificity 78.9%) and PTH (AUC 0.914; sensitivity 100%, specificity 73.7%) one week postparathyroidectomy. EVOLUTION follow-up 30 ± 16.3 months: 50% normalized PTH and 8.3% had recurrence of hyperparathyroidism. Patients with PPNCHPPT less frequently received preoperative treatment with bisphosphonates and postoperative treatment with calcium salts. CONCLUSIONS This is the first study in our country that demonstrates a mean prevalence of PPNCHPPT, mainly related to a vitamin D deficiency and a probable resistance to the action of PTH, which can be predicted by the PTH/ACC ratio and PTH a week post-intervention and often evolves normalizing the PTH. We disagree with the etiological effect of hypercalciuria and the change in the PTH/calcemia regulation set point, and we acknowledge the scant treatment administered with calcium salts in the postoperative period.
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Affiliation(s)
- Luis García Pascual
- Servei d'Endocrinologia, Hospital Universitari Mútua de Terrasa, Terrassa, Spain.
| | - Andreu Simó-Servat
- Servei d'Endocrinologia, Hospital Universitari Mútua de Terrasa, Terrassa, Spain
| | - Carlos Puig-Jové
- Servei d'Endocrinologia, Hospital Universitari Mútua de Terrasa, Terrassa, Spain
| | - Lluís García-González
- Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari Arnau de Vilanova, Lleida, Spain
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Richards BA, Vierkant RA, Dy BM, Foster TR, McKenzie TJ, Lyden ML. Intraoperative Parathyroid Hormone Monitoring Is of Limited Usefulness in Guiding Autotransplantation in Reoperative or Subtotal Parathyroidectomy for Primary Hyperparathyroidism. Am Surg 2023; 89:5421-5427. [PMID: 36786277 DOI: 10.1177/00031348231156758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION Patients with primary hyperparathyroidism (1HPT) undergoing reoperative or subtotal parathyroidectomy (PTX) may undergo autotransplantation (ATX) when the viability of remaining tissue is unknown. This study aims to identify whether intraoperative parathyroid hormone levels (IOPTH) can determine ATX candidacy. METHODS Patients with 1HPT who underwent PTX with ATX at our institution were identified. IOPTH and PTH values within 24 h, 2-4 weeks, and >1 month postoperative were analyzed. Patients were classified as either a candidate for ATX (low PTH after 2-4 weeks) or not a candidate based on postoperative PTH (normal PTH after 2-4 weeks). Associations of ATX candidate status with demographic and clinical attributes were studied. RESULTS 268 had a reoperative (49%) or subtotal PTX with ATX. 151 had data for PTH analysis, and 21 (14%) were identified as candidates for ATX. The mean % decline in IOPTH from baseline to 20 min post-excision was 51% in noncandidates vs 73% in candidates (P = .002). The mean change in IOPTH from baseline to final was 52% in noncandidates and 83% in candidates (P = .009). A decrease in IOPTH from baseline to 20 min post-excision of 23.4% or greater or a final PTH of 52 pg/mL or less would be an indication for ATX. Of the 21 who needed an ATX, it failed in 10. CONCLUSION Parathyroid ATX is frequently unnecessary, and the viability is less than expected. While candidates for ATX have a greater IOPTH % decline at all points during surgery and a lower final IOPTH, the clinical practicality of using IOPTH to determine ATX candidacy is limited.
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Affiliation(s)
| | - Robert A Vierkant
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Talbot JN, Périé S, Tassart M, Safa JB, Montravers F, Balogova S. The Presence of an Arteria Lusoria Should Be Checked When Reporting 18 F-FCH PET/CT Performed to Localize Hyperfunctioning Parathyroid Glands. Clin Nucl Med 2023; 48:958-959. [PMID: 37756414 PMCID: PMC10581409 DOI: 10.1097/rlu.0000000000004814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/11/2023] [Indexed: 09/29/2023]
Abstract
ABSTRACT Nonrecurrent inferior laryngeal nerve (NRILN) is a rare anatomical variant, which significantly increases the risk of nerve injury during neck surgery, for example, thyroidectomy or parathyroidectomy (PTX). The absence of the brachiocephalic trunk and presence of arteria lusoria (AL) are strong predictors of NRILN in the right neck. FCH PET/CT is now a recognized imaging modality in hyperparathyroidism (HPT). We report 2 patients with primary or renal HPT in whom FCH PET detected right HFPTs and low-dose noncontrast CT evidenced AL. The NRILN was thus preserved during PTX. We recommend searching for AL on FCH PET/CT (even low-dose) in HPT before PTX.
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Affiliation(s)
- Jean-Noël Talbot
- From the Service de Médecine Nucléaire, Hôpital Tenon, GH AP.SU, Paris
- Institut National des Sciences et Techniques Nucléaires, Saclay
| | - Sophie Périé
- Service de Chirurgie Cervico-faciale, Hôpital Tenon, GH AP.SU, Paris
- Service ORL et Chirurgie Cervico-faciale, Centre Hospitalier Privé Ambroise Paré/Hartmann, Neuilly sur Seine
| | - Marc Tassart
- Service de Radiologie, Hôpital Tenon, GH AP.SU, Paris, France
| | | | | | - Sona Balogova
- From the Service de Médecine Nucléaire, Hôpital Tenon, GH AP.SU, Paris
- Department of Nuclear Medicine, St Elisabeth Oncology Institute, Comenius University, Bratislava, Slovakia
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McClean A, England RJA. Revision parathyroid surgery - challenges and considerations in comparison to primary surgery. J Laryngol Otol 2023; 137:1233-1236. [PMID: 36938821 DOI: 10.1017/s002221512300049x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Revision parathyroidectomy is made necessary by recurrent or persistent parathyroid disease. This study aimed to identify challenges in revision surgery compared to primary parathyroid surgery. METHODS All revision parathyroidectomies performed by one surgeon over a 17-year period were assessed for demographics, imaging, histology, biochemistry, cure rate, gland weight, gland location and gland ectopia, and compared to a series of 100 primary parathyroidectomies. RESULTS Twenty-eight revision surgical procedures were identified. Sestamibi scanning for gland localisation was superior to ultrasound in both primary and revision surgery. Pre-operative calcium and gland weight were significantly higher in revision cases. There were no significant differences in post-operative calcium levels, pre- or post-operative parathyroid hormone levels, or gland location. 36 per cent of glands excised in revision surgery were ectopic, compared to 25 per cent in primary procedures. The cure rate was significantly lower in revision surgery. CONCLUSION Revision parathyroidectomy patients present with higher pre-operative calcium and larger adenomas; the cure rate is significantly lower in these patients.
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Affiliation(s)
- A McClean
- Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - R J A England
- ENT, Hull University Teaching Hospitals NHS Trust, Hull, UK
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Green RL, Fagenson AM, Karhadkar SS, Kuo LE. Does race impact outcomes after parathyroidectomy for secondary and tertiary hyperparathyroidism? Am J Surg 2023; 226:652-659. [PMID: 37453804 DOI: 10.1016/j.amjsurg.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Racial disparities in care exist for diseases with heterogeneous treatment guidelines. The impact of these disparities on outcomes after parathyroidectomy for secondary(2HPT) and tertiary hyperparathyroidism(3HPT) was explored. METHODS The 2015-2019 NSQIP datasets were used. Patients who underwent parathyroidectomy for 2HPT and 3HPT were identified and analyzed separately. Patients were stratified by race (white vs. non-white); demographics, comorbidities, and outcomes were compared. Studied outcomes included 30-day morbidity, mortality, unplanned reoperation, readmission, and postoperative length of stay(LOS). RESULTS There were 1,150 patients with 2HPT and 262 with 3HPT. For 2HPT, 65.5% were non-white; morbidity, reoperation, and prolonged LOS(>3days) occurred disproportionately more often in non-white patients. Non-white race was independently associated with morbidity; higher ASA class and alkaline phosphatase levels were associated with prolonged LOS. For 3HPT, 53.1% were non-white; a prolonged LOS(>1day) occurred disproportionately more often in non-white patients. Higher alkaline phosphatase levels were independently associated with prolonged LOS. CONCLUSION Race and markers of advanced disease negatively impact outcomes after parathyroidectomy for 2HPT and 3HPT. Attention to racial disparities and earlier referral may positively impact outcomes.
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Affiliation(s)
- Rebecca L Green
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA.
| | | | - Sunil S Karhadkar
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Lindsay E Kuo
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA.
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Sada A, Hanson KT, Habermann EB, McKenzie TJ, Lyden ML, Foster TR, Clarke BL, Dy BM. Disparities in Parathyroidectomy: Who Receives Appropriate Treatment for Primary Hyperparathyroidism? J Surg Res 2023; 291:151-157. [PMID: 37399633 DOI: 10.1016/j.jss.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Parathyroidectomy is underperformed despite clear benefits in primary hyperparathyroidism (PHPT). We evaluated disparities in receipt of parathyroidectomy following PHPT diagnosis to explore barriers to care. METHODS Adults diagnosed with PHPT 2013-2018 at a health system were identified. Recommended indications for parathyroidectomy include age ≤50 y, calcium >11 mg/dL, or the presence of nephrolithiasis, hypercalciuria, nephrocalcinosis, decreased glomerular filtration rate, osteopenia, osteoporosis, or pathological fracture 1 y prior to diagnosis. Kaplan-Meier analysis assessed rates of parathyroidectomy within 12 mo following diagnosis as well as median time to parathyroidectomy, and multivariable Cox proportional hazards analyses assessed factors associated with undergoing parathyroidectomy. RESULTS Of 2409 patients, 75% were females, 12% aged ≤50 y, and 92% non-Hispanic White, while 52% had Medicaid/Medicare, 36% were commercial/self-pay or uninsured, and 12% unknown. Parathyroidectomy was performed within 1 y in 50% of patients. Within the 68% that met recommendations, parathyroidectomy was performed within 1 y in 54%; median time from diagnosis to surgery was shorter for males, patients aged ≤50 y, commercial/self-pay/no insurance patients (versus Medicaid/Medicare), and those with fewer comorbidities, P < 0.05. Multivariable analysis demonstrated non-Hispanic White patients and those with commercial/self-pay/uninsured were more likely to undergo parathyroidectomy after adjusting for comorbidity, age, and facility site. Among those strongly indicated, patients not on Medicare/Medicaid and aged ≤50 y were more likely to undergo parathyroidectomy after adjusting for race, comorbidity, and facility site. CONCLUSIONS Disparities in parathyroidectomy for PHPT were observed. Insurance type was associated with undergoing parathyroidectomy; patients on governmental insurance were less likely to undergo surgery and waited longer for surgery despite strong indications. Barriers to referral and access to surgery should be investigated and addressed to optimize all patients' access to care.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kristine T Hanson
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Bart L Clarke
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Ohshiro Y. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:eL230279. [PMID: 37983793 DOI: 10.7326/l23-0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
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Sayed S, Das A, Turner B, Wadhwa VS, Pathak KA. Role of four-dimensional computer tomography (4D-CT) in non-localising and discordant first-line imaging in primary hyperparathyroidism. Ann R Coll Surg Engl 2023; 105:739-746. [PMID: 36748800 PMCID: PMC10618046 DOI: 10.1308/rcsann.2022.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Accurate preoperative localisation of parathyroid adenoma is imperative for the success of minimally invasive parathyroidectomy (MIP). OBJECTIVE Our study aimed to evaluate the role of four-dimensional computer tomography (4D-CT) scan as an imaging modality in patients with failed and discordant localisation reported in the first-line imaging modalities (ultrasonography and 99mTc-MIBI-SPECT/CT). METHODS This is a prospective cohort study performed at a university teaching centre from March 2013 to July 2021. All patients with primary hyperparathyroidism who had failed localisation by ultrasonography and 99mTc-MIBI-SPECT/CT (SpCT), or discordance between them, had 4D-CT performed in this study. RESULTS One hundred and two sporadic cases of pHPT with failed/discordant first-line imaging had 4D-CT imaging prior to parathyroidectomy. In 102 patients, 105 parathyroid adenomas were reported on histopathology. 4D-CT was able to localise 78% of them to the correct side and 64% to the correct quadrant in 102 patients, as compared with US (correct side 21%, correct quadrant 16%) and 99mTc-MIBI-SPECT/CT (correct side 36%, correct quadrant 31%). 4D-CT had a sensitivity, precision, accuracy and F1 score for correct quadrant localisation as 79%, 81%, 66% and 80%; and for correct side localisation as 82%, 98%, 80% and 89%, respectively. 4D-CT was able to identify three ectopic adenomas (two in superior mediastinum and one in the oesophageal wall) which were not detected on US or SpCT. CONCLUSION 4D-CT was found to be sensitive and accurate in preoperative localising of the diseased parathyroid glands after failed/discordant US and SpCT. This led to more patients being offered MIP as the primary surgery and improved operative outcomes.
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Affiliation(s)
- S Sayed
- CancerCare Manitoba, Winnipeg, Canada
| | - A Das
- Dr. Bhubaneswar Borooah Cancer Institute, Guwahati, India
| | - B Turner
- CancerCare Manitoba, Winnipeg, Canada
| | - V S Wadhwa
- Cedars Sinai Medical Center, Los Angeles, USA
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Wang X, Zeng S. Multidisciplinary team model for the treatment of a patient with secondary hyperparathyroidism. Asian J Surg 2023; 46:4762-4763. [PMID: 37270317 DOI: 10.1016/j.asjsur.2023.05.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/17/2023] [Indexed: 06/05/2023] Open
Affiliation(s)
- Xie Wang
- Department of Anesthesiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Si Zeng
- Department of Anesthesiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Seib CD, Ganesan C, Tamura MK. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:eL230280. [PMID: 37983791 DOI: 10.7326/l23-0280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Division of General Surgery, Palo Alto Veterans Affairs Health Care System, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California
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Wu C, Gillis A, Sidani M, Mcleod C, Fazendin J, Chen H, Ramonell K, Lindeman B. Thresholds for surgical referral in primary hyperparathyroidism: A conjoint analysis. Am J Surg 2023; 226:640-645. [PMID: 37495466 PMCID: PMC10644944 DOI: 10.1016/j.amjsurg.2023.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) can be cured through surgery, but referral for treatment is often provider dependent. A conjoint analysis was performed to identify factors influencing referral for surgery. METHODS Online survey assessed endocrinologists and other physicians who reviewed 10 patient scenarios. They decided whether to refer for surgery or medical management based on clinical (age, comorbidities, etc) and biochemical factors (mild or classic disease). RESULTS Classic PHPT, age below 50, absence of comorbidities, presence of osteoporosis, and seeing a surgical provider significantly increased the likelihood of surgery referral (p < 0.001). Physician characteristics such as gender, practice duration, and setting did not have a significant influence. CONCLUSION Despite published benefits of surgery, non-surgical physicians were less likely to refer PHPT patients for surgical treatment if patients were older (age ≥ 50), had comorbid conditions, or had mild disease. More education and advocacy are needed for improved access to surgery.
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Affiliation(s)
- Christopher Wu
- Department of Surgery, Division of Breast and Endocrine Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Andrea Gillis
- Department of Surgery, Division of Breast and Endocrine Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mohamad Sidani
- Department of Surgery, Texas Tech University, Lubbock, TX, USA
| | - Chandler Mcleod
- Department of Surgery, Division of Breast and Endocrine Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica Fazendin
- Department of Surgery, Division of Breast and Endocrine Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, Division of Breast and Endocrine Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kimberly Ramonell
- University Pittsburgh Medical Center, Department of Surgery, Division of Endocrine Surgery, Pittsburgh, PA, USA
| | - Brenessa Lindeman
- Department of Surgery, Division of Breast and Endocrine Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Vaghaiwalla TM, Armstrong VL, Saghira C, Lew JI. Operative success is achieved regardless of ioPTH criterion used during focused parathyroidectomy for sporadic primary hyperparathyroidism. Am J Surg 2023; 226:604-608. [PMID: 37438175 DOI: 10.1016/j.amjsurg.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/27/2023] [Accepted: 06/24/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Focused parathyroidectomy (F-PTX) guided by intraoperative parathormone (ioPTH) monitoring may result in higher operative failure rates from missed multiglandular disease (MGD) in patients with sporadic primary hyperparathyroidism (spHPT) when ioPTH levels do not reach normal range. METHODS A retrospective review included 690 patients with spHPT who underwent F-PTX and ioPTH monitoring were divided into 2 groups: >50% ioPTH decrease to normal range, and >50% ioPTH decrease to above normal range. Operative success, recurrence, bilateral/unilateral neck exploration (BNE/UNE), MGD were evaluated. RESULTS 533 patients demonstrated >50% ioPTH decrease to normal range, and 157 patients >50% ioPTH decrease to above normal range. There were no differences in operative success 99% vs. 97%, recurrence 2.5% vs. 5%, BNE 12% vs. 11%, UNE 4% vs. 5%, or MGD 4% vs. 4%, (p > 0.05) with 46 months mean follow-up. CONCLUSIONS There were no differences in operative success, failure, BNE, UNE or MGD regardless of ioPTH criterion used for F-PTX.
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Affiliation(s)
- Tanaz M Vaghaiwalla
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
| | | | - Cima Saghira
- DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - John I Lew
- Division of Endocrine Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Gimbel S, Bartsch DK. [Use of near-infrared autofluorescence for intraoperative identification of parathyroid glands in primary hyperparathyroidism-A randomized study]. Chirurgie (Heidelb) 2023; 94:959-960. [PMID: 37782320 DOI: 10.1007/s00104-023-01968-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Sarah Gimbel
- Klinik für Viszeral‑, Thorax- und Gefäßchirurgie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland.
| | - Detlef K Bartsch
- Klinik für Viszeral‑, Thorax- und Gefäßchirurgie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland
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Kavazis C, Romanidis K, Pitiakoudis M, Kesisoglou I, Laskou S, Sapalidis K. The role of prophylactic parathyroidectomy during thyroidectomy for MTC in patients with MEN2A syndrome. Folia Med (Plovdiv) 2023; 65:720-727. [PMID: 38351753 DOI: 10.3897/folmed.65.e86749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/08/2022] [Indexed: 02/16/2024] Open
Abstract
AIM To define the role of prophylactic parathyroidectomy in the surgical treatment of medullary thyroid carcinoma (MTC) in multiple endocrine neoplasia type IIa (MEN2A) syndrome through a literature review.
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Affiliation(s)
- Christos Kavazis
- General University Hospital of Alexandroupolis, Alexandroupolis, Greece
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DeHoog RJ, King ME, Keating MF, Zhang J, Sans M, Feider CL, Garza KY, Bensussan A, Krieger A, Lin JQ, Badal S, Alore E, Pirko C, Brahmbhatt K, Yu W, Grogan R, Eberlin LS, Suliburk J. Intraoperative Identification of Thyroid and Parathyroid Tissues During Human Endocrine Surgery Using the MasSpec Pen. JAMA Surg 2023; 158:1050-1059. [PMID: 37531134 PMCID: PMC10398548 DOI: 10.1001/jamasurg.2023.3229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/08/2023] [Indexed: 08/03/2023]
Abstract
Importance Intraoperative identification of tissues through gross inspection during thyroid and parathyroid surgery is challenging yet essential for preserving healthy tissue and improving outcomes for patients. Objective To evaluate the performance and clinical applicability of the MasSpec Pen (MSPen) technology for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively. Design, Setting, and Participants In this diagnostic/prognostic study, the MSPen was used to analyze 184 fresh-frozen thyroid, parathyroid, and lymph node tissues in the laboratory and translated to the operating room to enable in vivo and ex vivo tissue analysis by endocrine surgeons in 102 patients undergoing thyroidectomy and parathyroidectomy procedures. This diagnostic study was conducted between August 2017 and March 2020. Fresh-frozen tissues were analyzed in a laboratory. Clinical analyses occurred in an operating room at an academic medical center. Of the analyses performed on 184 fresh-frozen tissues, 131 were included based on sufficient signal and postanalysis pathologic diagnosis. From clinical tests, 102 patients undergoing surgery were included. A total of 1015 intraoperative analyses were performed, with 269 analyses subject to statistical classification. Statistical classifiers for discriminating thyroid, parathyroid, and lymph node tissues were generated using training sets comprising both laboratory and intraoperative data and evaluated on an independent test set of intraoperative data. Data were analyzed from July to December 2022. Main Outcomes and Measures Accuracy for each tissue type was measured for classification models discriminating thyroid, parathyroid, and lymph node tissues using MSPen data compared to gross analysis and final pathology results. Results Of the 102 patients in the intraoperative study, 80 were female (78%) and the median (IQR) age was 52 (42-66) years. For discriminating thyroid and parathyroid tissues, an overall accuracy, defined as agreement with pathology, of 92.4% (95% CI, 87.7-95.4) was achieved using MSPen data, with 82.6% (95% CI, 76.5-87.4) accuracy achieved for the independent test set. For distinguishing thyroid from lymph node and parathyroid from lymph node, overall training set accuracies of 97.5% (95% CI, 92.8-99.1) and 96.1% (95% CI, 91.2-98.3), respectively, were achieved. Conclusions and Relevance In this study, the MSPen showed high performance for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively, suggesting this technology may be useful for providing near real-time feedback on tissue type to aid in surgical decision-making.
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Affiliation(s)
- Rachel J. DeHoog
- Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Mary E. King
- Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Chemistry, The University of Texas at Austin, Austin
| | | | - Jialing Zhang
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Marta Sans
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Clara L. Feider
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Kyana Y. Garza
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Alena Bensussan
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Anna Krieger
- Department of Chemistry, The University of Texas at Austin, Austin
| | - John Q. Lin
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Sunil Badal
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Elizabeth Alore
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | | | - Wendong Yu
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Raymon Grogan
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Livia S. Eberlin
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - James Suliburk
- Department of Surgery, Baylor College of Medicine, Houston, Texas
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Tyagi A, Nigam C, Pangtey R, Agrawal V. Severe unprovoked hypertrophic obstructive cardiomyopathy: anaesthetic concerns in patient undergoing parathyroidectomy. BMJ Case Rep 2023; 16:e254641. [PMID: 37730419 PMCID: PMC10514619 DOI: 10.1136/bcr-2023-254641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
This case highlights the role of an anaesthetist as a perioperative physician involved in diagnosing and optimising asymptomatic but severe hypertrophic obstructive cardiomyopathy. The modifications in anaesthetic technique for safe conduct of general anaesthesia during parathyroidectomy in a patient are also presented. These include those due to an extremely high left ventricular outflow tract obstruction with echocardiographic Doppler-derived maximum pressure gradient of 105 mm Hg at rest.
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Affiliation(s)
- Asha Tyagi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences, Dilshad Garden, Delhi, India
| | - Chanchal Nigam
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences, Dilshad Garden, Delhi, India
| | - Richa Pangtey
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences, Dilshad Garden, Delhi, India
| | - Vinayak Agrawal
- Department of Clinical Cardiology, Fortis Memorial Research Institute, Gurgaon, Haryana, India
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Soto-Pedre E, Newey PJ, Leese GP. Stable Incidence and Increasing Prevalence of Primary Hyperparathyroidism in a Population-based Study in Scotland. J Clin Endocrinol Metab 2023; 108:e1117-e1124. [PMID: 37022975 PMCID: PMC10505547 DOI: 10.1210/clinem/dgad201] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/23/2023] [Accepted: 04/04/2023] [Indexed: 04/07/2023]
Abstract
CONTEXT Previous studies, including our own, have demonstrated a highly variable incidence of primary hyperparathyroidism (PHPT) from year to year. OBJECTIVE We planned to provide a current estimate of the incidence and prevalence of PHPT in a community-based study. METHODS A population-based retrospective follow-up study was conducted in Tayside (Scotland) from 2007 to 2018. Record-linkage technology (demography, biochemistry, prescribing, hospital admissions, radiology, and mortality data) was used to identify all patients. Cases of PHPT were defined as those with at least 2 raised serum corrected calcium concentration CCA (> 2.55 mmol/L) and/or hospital admissions with PHPT diagnoses and/or surgery records with parathyroidectomy during the follow-up period. The number of prevalent and incident cases of PHPT per calendar year by age and sex were estimated. RESULTS A total of 2118 people (72.3% female, mean age 65 years) were identified with an incident case of PHPT. The overall prevalence of PHPT over the 12 years of the study was 0.84% (95% CI, 0.68%-1.02%), steadily increasing from 0.71% in 2007 to 1.02% in 2018. From 2008, the incidence of PHPT was relatively stable from 4 to 6 cases per 10 000 person-years, declining from 11.5 per 10 000 person-years in 2007. The incidence varied from 0.59 per 10 000 person-years (95% CI, 0.40%-0.77%) for those aged 20 to 29 years, to 12.4 per 10 000 person-years (95% CI, 11.2%-13.3%) in those aged 70 to 79 years. Incidence of PHPT was 2.5 times higher in women than in men. CONCLUSION This study is the first showing a relatively steady annual incidence of PHPT at 4 to 6 per 10 000 person-years. This population-based study reports a PHPT prevalence of 0.84%.
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Affiliation(s)
- Enrique Soto-Pedre
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Paul J Newey
- Department of Endocrinology and Diabetes, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Graham P Leese
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
- Department of Endocrinology and Diabetes, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
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Melot C, Deniziaut G, Menegaux F, Chereau N. Incidental parathyroidectomy during total thyroidectomy and functional parathyroid preservation: a retrospective cohort study. BMC Surg 2023; 23:269. [PMID: 37674156 PMCID: PMC10481605 DOI: 10.1186/s12893-023-02176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND The published rate of incidental parathyroidectomy (IP) during thyroid surgery varies between 5.8% and 29%. The risk factors and clinical significance of postoperative transient hypocalcemia and permanent hypoparathyroidism are still debated. The aims of this study were to assess the clinical relevance of avoidable IP for transient hypocalcemia and permanent hypoparathyroidism, and to describe the risk factors for IP. METHODS This retrospective cohort study included 1,537 patients who had a one-step total thyroidectomy in a high-volume endocrine surgery center between 2018 and 2019. Pathology reports were reviewed for incidentally removed parathyroid glands. Intrathyroidal parathyroid glands were excluded from the study. Demographic characteristics, potential risk factors, and postoperative calcium and PTH levels were compared between IP and control groups. RESULTS Avoidable IP occurred in 234 (15.2%) patients. Patients with IP had a higher risk of transient hypocalcemia (17.9% vs. 11.5%, p = 0.006; odds ratio [OR] 1.68, 95% confidence interval [95% CI]1.16-2.45) and permanent hypoparathyroidism (4.7% vs. 1.6%, p = 0.002; OR 3.01, 95% CI 1.29-6.63) than patients without IP. Multivariate analysis showed that central lymph node dissection (CLND) and incidental removal of thymus tissue were independent risk factors for IP (OR 4.83, 95% CI 2.71-8.86, p < 0.001 and OR 1.72, 95% CI 1.02-2.82, p = 0.038). CONCLUSIONS Patients with IP were more likely to develop transient hypocalcemia and permanent hypoparathyroidism, indicating the clinical significance of avoidable IP for patients and the need for raising awareness among surgeons. Patients undergoing CLND are at a higher risk for IP, and should be adequately informed and treated. Any removal of thymus tissue should be avoided during CLND.
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Affiliation(s)
- Charlotte Melot
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de L'Hôpital, Paris, 75013, France.
| | - Gabrielle Deniziaut
- Department of Pathology, Pitié Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
- Groupe de Recherche Clinique N°16 Thyroid Tumors, Sorbonne University, Paris, France
| | - Fabrice Menegaux
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de L'Hôpital, Paris, 75013, France
- Groupe de Recherche Clinique N°16 Thyroid Tumors, Sorbonne University, Paris, France
| | - Nathalie Chereau
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de L'Hôpital, Paris, 75013, France
- Groupe de Recherche Clinique N°16 Thyroid Tumors, Sorbonne University, Paris, France
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Smith R, Bulteel N, Alfonzo A, Gupta S. Successful treatment of severe calciphylaxis in a renal transplant patient with previous total parathyroidectomy. J R Coll Physicians Edinb 2023; 53:207-211. [PMID: 37427771 DOI: 10.1177/14782715231184519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Calciphylaxis is a rare dermatological condition strongly associated with chronic kidney disease. The pathophysiology and optimum treatment remain uncertain. Calciphylaxis is known mostly to affect dialysis patients but is less frequently reported in renal transplant recipients. We report the case of a renal transplant recipient who had undergone previous total parathyroidectomy.
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Affiliation(s)
- Rachel Smith
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
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