1
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Chang LC, Liu SI, Liang TJ. Neck Reoperation for Recurrent or Persistent Renal Hyperparathyroidism. World J Surg 2023; 47:2784-2791. [PMID: 37714965 DOI: 10.1007/s00268-023-07172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Patients with renal hyperparathyroidism undergoing parathyroidectomy may experience relapse. Reoperation for persistent or recurrent disease, particularly in the neck region, is challenging and has a high complication rate because of difficult exploration. We aimed to evaluate the effectiveness of neck reoperation in renal hyperparathyroidism. METHODS Patients with recurrent or persistent renal hyperparathyroidism who underwent neck reoperation between January 2015 and August 2022 were investigated, focusing on operative findings, perioperative biochemical changes, and significance of intraoperative parathyroid hormone (PTH) measurements. RESULTS During reoperation, 35 parathyroid glands were identified and removed from the 26 enrolled patients, with one, two, and three glands retrieved from 19 (73.2%), five (19.2%), and two (7.6%) patients, respectively. Most removed glands (68.6%) were located in the lower neck, followed by the mediastinum, carotid sheath, and upper neck. Successful resection, defined as a postoperative PTH level of <300 pg/mL, was achieved in 21 patients (80.8%). The remaining four (15.4%) and one (3.9%) patients were classified as having persistent and recurrent disease, respectively. The extent of PTH reduction was correlated with specimen weight, specimen volume, and preoperative alkaline phosphatase (ALP) level. The mean intraoperative PTH ratio (10 min after excision/pre-excision) was 0.23, and all patients with persistent or recurrent disease had a PTH ratio >0.3. Severe hypocalcemia (<7.5 mg/dL) occurred in 19 (73.0%) patients after reoperation. CONCLUSIONS Neck reoperation is an effective therapeutic option in patients with recurrent or persistent renal hyperparathyroidism. A decrease in PTH level by >70% during reoperation (PTH ratio <0.3) predicts successful resection.
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Affiliation(s)
- Lu-Chia Chang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414
| | - Shiuh-Inn Liu
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414
- School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec. 2, Linong Street, Taipei, Taiwan, 112304
| | - Tsung-Jung Liang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414.
- School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec. 2, Linong Street, Taipei, Taiwan, 112304.
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Yang J, Lu X, Zhou P, Liu H, Wang J, Su X. Recurrence hyperparathyroidism caused by synchronous parathyroid carcinoma and parathyromatosis in a patient with long-term hemodialysis. BMC Nephrol 2023; 24:293. [PMID: 37794407 PMCID: PMC10552215 DOI: 10.1186/s12882-023-03328-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/07/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Parathyroid carcinoma and parathyromatosis are very rare diseases in patients on hemodialysis. Its pathogenesis, clinical features, preoperative diagnosis, and surgery are challenging. We describe a rare case of recurrent hyperparathyroidism due to synchronous parathyroid carcinoma and parathyromatosis. CASE PRESENTATION A 46-year-old Chinese woman was diagnosed with end-stage renal disease and received regular hemodialysis. Four years later, she experienced discomfort due to itching and was diagnosed with drug-resistant secondary hyperparathyroidism. Parathyroidectomy was performed, and her parathyroid hormone (PTH) levels were reduced. The pathology also revealed that the four nodules were parathyroid nodular hyperplasia without evidence of malignancy. Five years after surgery, the right subcutaneous nodule and left inferior nodule were detected by multiple imaging modalities, and the nodules were accompanied by recurrence itching and elevation of PHT. A complete resection of two nodules was performed, and the patient was diagnosed with parathyroid carcinoma and parathyromatosis. At 8 months postsurgery, her PHT and serum calcium levels were stable, and there were no signs of recurrence. CONCLUSIONS This is a rare case of synchronous parathyroid carcinoma and parathyromatosis in a patient with secondary hyperparathyroidism after parathyroidectomy. We suggest meticulous handling of parathyroid hyperplasia to avoid rupture and spillage during surgery, and precise pro-operation location by multiple imaging modalities is crucial for successful parathyroidectomy.
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Affiliation(s)
- Jun Yang
- Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, P.R. China
| | - Xili Lu
- Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, P.R. China
| | - Pingping Zhou
- Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, P.R. China
| | - Hao Liu
- Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, P.R. China
| | - Jili Wang
- The Department of Pathology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, P.R. China
| | - Xinhui Su
- Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, P.R. China.
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3
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Jha S, Simonds WF. Molecular and Clinical Spectrum of Primary Hyperparathyroidism. Endocr Rev 2023; 44:779-818. [PMID: 36961765 PMCID: PMC10502601 DOI: 10.1210/endrev/bnad009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/09/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
Recent data suggest an increase in the overall incidence of parathyroid disorders, with primary hyperparathyroidism (PHPT) being the most prevalent parathyroid disorder. PHPT is associated with morbidities (fractures, kidney stones, chronic kidney disease) and increased risk of death. The symptoms of PHPT can be nonspecific, potentially delaying the diagnosis. Approximately 15% of patients with PHPT have an underlying heritable form of PHPT that may be associated with extraparathyroidal manifestations, requiring active surveillance for these manifestations as seen in multiple endocrine neoplasia type 1 and 2A. Genetic testing for heritable forms should be offered to patients with multiglandular disease, recurrent PHPT, young onset PHPT (age ≤40 years), and those with a family history of parathyroid tumors. However, the underlying genetic cause for the majority of patients with heritable forms of PHPT remains unknown. Distinction between sporadic and heritable forms of PHPT is useful in surgical planning for parathyroidectomy and has implications for the family. The genes currently known to be associated with heritable forms of PHPT account for approximately half of sporadic parathyroid tumors. But the genetic cause in approximately half of the sporadic parathyroid tumors remains unknown. Furthermore, there is no systemic therapy for parathyroid carcinoma, a rare but potentially fatal cause of PHPT. Improved understanding of the molecular characteristics of parathyroid tumors will allow us to identify biomarkers for diagnosis and novel targets for therapy.
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Affiliation(s)
- Smita Jha
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892-1752, USA
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892-1752, USA
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4
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Maximal parathyroid gland diameter as a predictive factor for autograft-dependent recurrent secondary hyperparathyroidism after total parathyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1175237. [PMID: 37396185 PMCID: PMC10311438 DOI: 10.3389/fendo.2023.1175237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Following total parathyroidectomy (PTx), transcervical thymectomy, and forearm autograft for secondary hyperparathyroidism (SHPT), recurrent SHPT can occur in the autografted forearm. However, few studies have investigated the factors contributing to re-PTx due to autograft-dependent recurrent SHPT before the completion of the initial PTx. Methods A total of 770 patients who had autografted parathyroid fragments derived from only one of the resected parathyroid glands (PTGs) and who had undergone successful initial total PTx and transcervical thymectomy-defined by serum intact parathyroid hormone level < 60 pg/mL on postoperative day 1-between January 2001 and December 2022 were included in this retrospective cohort study. Factors contributing to re-PTx due to graft-dependent recurrent SHPT before the completion of the initial PTx were investigated using multivariate Cox regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to obtain the optimal maximum diameter of PTG for autograft. Results Univariate analysis showed that dialysis vintage and maximum diameter and weight of the PTG for autograft were significant factors contributing to graft-dependent recurrent SHPT. However, multivariate analysis revealed that dialysis vintage (P=0.010; hazard ratio [HR], 0.995; 95% confidence interval [CI], 0.992-0.999) and the maximum diameter of the PTG for autograft (P=0.046; HR, 1.107; 95% CI, 1.002-1.224) significantly contributed to graft-dependent recurrent SHPT. ROC curve analysis showed that < 14 mm was the optimal maximum diameter of PTG for autograft (area under the curve, 0.628; 95% CI, 0.551-0.705). Conclusions The dialysis vintage and maximum diameter of PTG for autograft may contribute to re-PTx due to autograft-dependent recurrent SHPT, which can be prevented by using PTGs with a maximum diameter of < 14 mm for autograft.
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Treatment for secondary hyperparathyroidism focusing on parathyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1169793. [PMID: 37152972 PMCID: PMC10159274 DOI: 10.3389/fendo.2023.1169793] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/07/2023] [Indexed: 05/09/2023] Open
Abstract
Secondary hyperparathyroidism (SHPT) is a major problem for patients with chronic kidney disease and can cause many complications, including osteodystrophy, fractures, and cardiovascular diseases. Treatment for SHPT has changed radically with the advent of calcimimetics; however, parathyroidectomy (PTx) remains one of the most important treatments. For successful PTx, removing all parathyroid glands (PTGs) without complications is essential to prevent persistent or recurrent SHPT. Preoperative imaging studies for the localization of PTGs, such as ultrasonography, computed tomography, and 99mTc-Sestamibi scintigraphy, and intraoperative evaluation methods to confirm the removal of all PTGs, including, intraoperative intact parathyroid hormone monitoring and frozen section diagnosis, are useful. Functional and anatomical preservation of the recurrent laryngeal nerves can be confirmed via intraoperative nerve monitoring. Total or subtotal PTx with or without transcervical thymectomy and autotransplantation can also be performed. Appropriate operative methods for PTx should be selected according to the patients' need for kidney transplantation. In the case of persistent or recurrent SHPT after the initial PTx, localization of the causative PTGs with autotransplantation is challenging as causative PTGs can exist in the neck, mediastinum, or autotransplanted areas. Additionally, the efficacy and cost-effectiveness of calcimimetics and PTx are increasingly being discussed. In this review, medical and surgical treatments for SHPT are described.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
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Li L, He C, Cheng G, Cao J, Wang C, Tang Y, Zhang W. Recurrent renal secondary hyperparathyroidism caused by supernumerary mediastinal parathyroid gland and parathyromatosis: A case report. Front Surg 2023; 10:1135596. [PMID: 37021088 PMCID: PMC10067725 DOI: 10.3389/fsurg.2023.1135596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
Background Surgical parathyroidectomy (PTX) is necessary for patients with severe and progressive secondary hyperparathyroidism (SHPT) refractory to medical treatment. Recurrence of SHPT after PTX is a serious clinical problem. Both supernumerary mediastinal parathyroid gland and parathyromatosis are the rare causes of recurrent renal SHPT. We report a rare case of recurrent renal SHPT due to supernumerary mediastinal parathyroid gland and parathyromatosis. Case presentation A 53-year-old man underwent total parathyroidectomy with autotransplantation due to the drug-refractory SHPT 17 years ago. In the last 11 months, the patient experienced symptoms including bone pain and skin itch, and the serum intact parathyroid hormone (iPTH) level elevated to 1,587 pg/ml. Ultrasound detected two hypoechoic lesions located at the dorsal area of right lobe of the thyroid gland, and both lesions presented as characteristics of hyperparathyroidism in contrast-enhanced ultrasound. 99mTc-MIBI/SPECT detected a nodule in the mediastinum. A reoperation involved a cervicotomy for excising parathyromatosis lesions and the surrounding tissue and a thoracoscopic surgery for resecting a mediastinal parathyroid gland. According to a histological examination, two lesions behind the right thyroid lobe and one lesion in the central region had been defined as parathyromatosis. A nodule in the mediastinum was consistent with hyperplastic parathyroid. The patient remained well for 10 months with alleviated symptoms and stabilized iPTH levels in the range of 123-201 pg/ml. Conclusion Although rare, recurrent SHPT may be caused by a coexistence of both supernumerary parathyroid glands and parathyromatosis, which should receive more attention. The combination of imaging modalities is important for reoperative locations of parathyroid lesions. To successfully treat parathyromatosis, all the lesions and the surrounding tissue must be excised. Thoracoscopic surgery is a reliable and safe approach for the resection of ectopic mediastinal parathyroid glands.
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Affiliation(s)
- Longfei Li
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Chenchen He
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Department of Clinical Medicine and Surgery, China Medical University, Shenyang, China
| | - Guangming Cheng
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Junying Cao
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Chunhui Wang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yufu Tang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Correspondence: Yufu Tang Wei Zhang
| | - Wei Zhang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Correspondence: Yufu Tang Wei Zhang
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7
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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Yang J, Zhang J, Liu NH, Liu H, Dong MJ. Persistent secondary hyperparathyroidism caused by parathyromatosis and supernumerary parathyroid glands in a patient on haemodialysis. BMC Nephrol 2020; 21:257. [PMID: 32631272 PMCID: PMC7339528 DOI: 10.1186/s12882-020-01917-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/29/2020] [Indexed: 11/21/2022] Open
Abstract
Background Secondary hyperparathyroidism (SHPT) is a common high-risk factor for mortality in end-stage renal disease, and parathyromatosis and supernumerary parathyroid glands are very rare causes of persistent SHPT. Preoperative diagnosis and removal of all hyperplastic parathyroid glands are challenging. We report a rare case of persistent SHPT due to parathyromatosis and supernumerary parathyroid glands and successful management by multiple imaging modalities. Case presentation A 53-year-old Chinese woman on haemodialysis experienced discomfort due to itching and bone pain due to persistent SHPT after parathyroidectomy. The supernumerary parathyroid glands and parathyromatosis were detected by multiple imaging modalities, including 99mTc-sestamibi (99mTc-MIBI) scans, ultrasonography and four-dimensional computed tomography (4D-CT) and then excised; pathological confirmation was performed. During follow-up, her serum calcium and parathyroid hormone levels were stable in the appropriate ranges, and no complications arose. Conclusions Because of persistent SHPH after parathyroidectomy in patients with haemodialysis, multiple imaging modalities, including 99mTc-MIBI scans, 4D-CT and ultrasonography, are helpful for detecting supernumerary parathyroid glands and parathyromatoses. Accurate preoperative localization of this rare lesion is important for management, enabling the removal of all affected parathyroid tissues.
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Affiliation(s)
- Jun Yang
- The Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, 310003, Hangzhou, People's Republic of China
| | - Jun Zhang
- The Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, 310003, Hangzhou, People's Republic of China
| | - Ning-Hu Liu
- The Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, 310003, Hangzhou, People's Republic of China
| | - Hao Liu
- The Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, 310003, Hangzhou, People's Republic of China
| | - Meng-Jie Dong
- The Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, 310003, Hangzhou, People's Republic of China.
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Huang Y, Wu H, Wu Y, Luo Z. Efficacy analysis of medical and surgical treatments in chronic kidney disease patients with secondary hyperparathyroidism. Am J Otolaryngol 2019; 40:102228. [PMID: 31375304 DOI: 10.1016/j.amjoto.2019.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate the effects of surgical and medical treatments on chronic kidney disease (CKD) patients with secondary hyperparathyroidism (SHPT). MATERIALS AND METHODS A total of 198 CKD patients with SHPT were identified at Tongji Hospital from January 2013 to June 2017. RESULTS Surgical group (53 patients) received maintenance dialysis for 78.0 ± 4.9 months, while medical group (84 patients) for 62.0 ± 6.4 months. The serum intact parathyroid hormone (iPTH) in surgical group reduced apparently compared with medical group (P = 0.015) and maintained satisfied result during three years of follow-up (67.4 ± 7.4 pg/ml). The recurrence rate in surgical group was 7.5% and in medical group was 15.5% (P = 0.024). Beyond that, 5 (5.9%) patients suffered persistent hyperparathyroidism in medical group. CONCLUSION Although the progress of medical treatment is changing rapidly, surgical treatment is still an effective way to control serum iPTH and calcium chronically for SHPT patients. Complex SHPT patients can also receive satisfied effect by surgical treatment, without apparently increasing the risk of complications.
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10
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Wei AE, Garrett MR, Gupta A. PARATHYROMATOSIS: A RARE CASE OF RECURRENT HYPERPARATHYROIDISM LOCALIZED BY FOUR-DIMENSIONAL COMPUTED TOMOGRAPHY. AACE Clin Case Rep 2019; 5:e384-e387. [PMID: 31967077 DOI: 10.4158/accr-2019-0225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/08/2019] [Indexed: 11/15/2022] Open
Abstract
Objective To present a rare case of parathyromatosis. Methods We present the clinical, laboratory, and imaging findings, along with a review of the literature. Results A 33-year-old man with a history of right upper parathyroid adenoma removal 5 years prior due to hyperparathyroidism was admitted for severe hypercalcemia (15.6 mg/dL; normal, 8.5 to 10.5 mg/dL) with elevated plasma parathyroid hormone (PTH) (882 pg/mL; normal, 15 to 65 pg/mL). Ultrasound, computed tomography (CT), sestamibi, and positron emission tomography scans were unremarkable; however, a four-dimensional CT (4DCT) of the neck showed an area of increased signal enhancement and hypervascularity without discrete nodule in the posterior right thyroid region. The patient underwent parathyroid surgical exploration with right hemithyroidectomy and compartment neck dissection to remove the affected tissue. PTH levels dropped to 208 pg/mL postoperatively; calcium decreased but remained elevated at 12.7 mg/dL. Pathology revealed the presence of several small nodular foci of atypical hyperplastic parathyroid tissue in the right thyroid and soft tissue in the left central neck compartment consistent with parathyromatosis. Conclusion This case report represents the first-time use of 4DCT to localize parathyromatosis. Parathyromatosis is a rare but problematic cause of recurrent hyperparathyroidism. Ultrasound and 4DCT may represent the best imaging modalities for identification and perioperative management to remove all affected tissue without reseeding.
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11
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Miller MJ, Agrawal N, Katz G, Ogilvie J, Melamed J. Parathyromatosis with a papillary architecture. Histopathology 2019; 75:598-602. [PMID: 31152597 DOI: 10.1111/his.13928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - Nidhi Agrawal
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY, USA
| | - Gillian Katz
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY, USA
| | - Jennifer Ogilvie
- Department of Surgery, Division of Endocrine Surgery, NYU Langone Health, New York, NY, USA
| | - Jonathan Melamed
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY, USA
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12
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Jain M, Krasne DL, Singer FR, Giuliano AE. Recurrent primary hyperparathyroidism due to Type 1 parathyromatosis. Endocrine 2017; 55:643-650. [PMID: 27743301 DOI: 10.1007/s12020-016-1139-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/24/2016] [Indexed: 10/20/2022]
Abstract
Parathyromatosis is a rare condition consisting of multiple nodules of benign hyperfunctioning parathyroid tissue scattered throughout the neck and superior mediastinum. As a potential cause of recurrent or persistent hyperparathyroidism, parathyromatosis is a challenging condition to diagnose and treat. The optimal evaluation and management of patients with parathyromatosis is not well established. The reported case involves a patient who was initially diagnosed with primary hyperparathyroidism. The diagnosis of Type 1 parathyromatosis was made after the patient developed recurrent hyperparathyroidism with hypercalcemia and osteoporosis 17 years after the initial operation and underwent two additional operations. The majority of parathyromatosis cases are diagnosed in the setting of secondary hyperparathyroidism. Consensus regarding the preoperative diagnosis and evaluation is lacking due to the paucity of cases of this rare clinical entity. Management involves complete surgical extirpation of all identifiable rests of parathyroid tissue. Intra-operative parathyroid hormone level monitoring and frozen section examination are excellent tools that could increase the rates of initial operative success. Despite this, long-term disease remission is rare, and medical therapy, including calcimimetics and bisphosphonates, may be required for postoperative or non-operative management.
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Affiliation(s)
- Monica Jain
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
| | - David L Krasne
- Department of Pathology, Providence Saint John's Health Center, 2121 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Frederick R Singer
- Endocrine/Bone Disease Program, John Wayne Cancer Institute at Providence Saint John's Health Center, 2121 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
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13
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Nakamura M, Tanaka K, Fujii T. Hyperparathyroidism caused by distant pulmonary lesions and parathyromatosis after ethanol injection/parathyroidectomy for secondary hyperparathyroidism. Hemodial Int 2017; 21:E45-E49. [PMID: 28078796 DOI: 10.1111/hdi.12525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Secondary hyperparathyroidism (SHPT) treatment includes parathyroidectomy and percutaneous ethanol injection therapy (PEIT), which are invasive procedures. The condition in which benign hyperfunctioning parathyroid tissue is distributed throughout the neck and mediastinum is termed parathyromatosis. Here, we present the case of a 51-year-old woman who began hemodialysis in 1986 due to chronic kidney disease of unknown etiology and developed SHPT in 1999. She underwent 6 rounds of PEIT followed by total a parathyroidectomy with partial forearm autotransplantation. Between 2011 and 2013, surgeons removed several nodules from her pulmonary and cervical regions and the transplanted masses from her forearm; all showed hyperplasia but exhibited no histological evidence of malignancy. Damage to the parathyroid capsule after repeated PEITs may cause local cervical recurrence and pulmonary lesions, although distant lesions are extremely rare in SHPT. This case is of interest due to the possible association between PEIT and parathyromatosis and distal lesions.
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Affiliation(s)
- Michio Nakamura
- Department of Transplant Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | | | - Takeshi Fujii
- Department of Pathology, Toranomon Hospital, Minatoku, Tokyo, Japan
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14
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Achour I, Charfi S, Chaabouni MA, Chakroun A, Guermazi F, Hammami B, Ghorbel A. [Parathyromatosis: An uncommon cause of recurrent hyperparathyroidism]. Rev Med Interne 2016; 38:61-64. [PMID: 27083335 DOI: 10.1016/j.revmed.2016.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 03/15/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Parathyromatosis is a rare cause of recurrent hyperparathyroidism. It results from hyperfunctioning parathyroid tissue scattered throughout the thyroid bed region. CASE REPORT A 51-year-old man with a history of parathyroidectomy, presented 18 years later with recurrent primary hyperparathyroidism. Surgical exploration identified a single parathyroid gland. The act was completed by a central compartment dissection and ipsilateral lobectomy. The patient was free of recurrence after a one-year follow-up. CONCLUSION Parathyromatosis a rare cause of recurrent hyperparathyroidism. Its management is challenging. Extensive surgery is required with clearance of the central neck compartment and homolateral lobectomy. Medical therapy could be used to decrease parathormone level in recurrent parathyromatosis.
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Affiliation(s)
- I Achour
- Service ORL, chirurgie cervico-faciale, CHU Habib Bourguiba, 3029 Sfax, Tunisie.
| | - S Charfi
- Laboratoire d'anatomie et de cytologie pathologiques, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - M A Chaabouni
- Service ORL, chirurgie cervico-faciale, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - A Chakroun
- Service ORL, chirurgie cervico-faciale, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - F Guermazi
- Service de médecine nucléaire, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - B Hammami
- Service ORL, chirurgie cervico-faciale, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - A Ghorbel
- Service ORL, chirurgie cervico-faciale, CHU Habib Bourguiba, 3029 Sfax, Tunisie
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15
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Tominaga Y. Current status of parathyroidectomy for secondary hyperparathyroidism in Japan. NDT Plus 2015; 1:iii35-iii38. [PMID: 25983971 PMCID: PMC4421124 DOI: 10.1093/ndtplus/sfn085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 02/29/2008] [Indexed: 02/07/2023] Open
Affiliation(s)
- Yoshihiro Tominaga
- Department of Transplant and Endocrine Surgery , Nagoya Second Red Cross Hospital , Nagoya , Japan
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16
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Callender GG, Udelsman R. Surgery for primary hyperparathyroidism. Cancer 2014; 120:3602-16. [DOI: 10.1002/cncr.28891] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 03/24/2014] [Accepted: 03/31/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Glenda G. Callender
- Department of Surgery; Section of Endocrine Surgery, Yale University School of Medicine; New Haven Connecticut
| | - Robert Udelsman
- Department of Surgery; Section of Endocrine Surgery, Yale University School of Medicine; New Haven Connecticut
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17
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Affiliation(s)
- Tsung-Jui Wu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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18
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Hage MP, Salti I, El-Hajj Fuleihan G. Parathyromatosis: a rare yet problematic etiology of recurrent and persistent hyperparathyroidism. Metabolism 2012; 61:762-75. [PMID: 22221828 DOI: 10.1016/j.metabol.2011.11.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 10/31/2011] [Accepted: 11/02/2011] [Indexed: 11/29/2022]
Abstract
Recurrent or persistent hyperparathyroidism is an uncommon yet challenging clinical problem, and parathyromatosis is one of its very rare causes. In this minireview, we review causes of recurrent hyperparathyroidism and all cases of parathyromatosis available in the literature. The clinical course of a case of parathyromatosis with the longest follow-up (1977-2011) is described. Similar cases reported between 1975 and the present are reviewed and analyzed to characterize the clinical presentation, course, and management of this rare condition. Parathyromatosis, which is benign parathyroid tissue seeding, has been detailed in 35 patients in the English literature. The majority were female subjects, with end-stage renal disease, in their fifth to sixth decade of life. In most cases, the diagnosis was made intraoperatively; and the condition was often refractory to surgery. A calcimimetic agent was used in 5 cases with end-stage renal disease; serum calcium and/or parathyroid hormone levels decreased in 4 subjects, but only one was reported to experience increments in bone density. Medical management combining a calcimimetic with a bisphosphonate may therefore be a preferred alternative.
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Affiliation(s)
- Mirella P Hage
- Department of Internal Medicine, Division of Endocrinology, American University of Beirut-Medical Center, Riad El Solh 1107 2020, Beirut, Lebanon
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19
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Aksoy-Altinboga A, Akder Sari A, Rezanko T, Haciyanli M, Orgen Calli A. Parathyromatosis: critical diagnosis regarding surgery and pathologic evaluation. KOREAN JOURNAL OF PATHOLOGY 2012; 46:197-200. [PMID: 23110001 PMCID: PMC3479781 DOI: 10.4132/koreanjpathol.2012.46.2.197] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 03/15/2011] [Accepted: 04/18/2011] [Indexed: 11/17/2022]
Abstract
Parathyromatosis, in which several nodules of hyperfunctioning parathyroid tissue form in the neck and mediastinum, is a rare cause of recurrent hyperparathyroidism. However, there are some theories regarding the origin of parathyromatosis, and seeding after rupture of the parathyroid gland capsule during surgical removal of a parathyroid lesions is the most regarded one. Herein, we report a 41-year-old man who presented with multiple parathyroid nodules in and around the left thyroid lobe 5 years after parathyroid surgery for secondary hyperparathyroidism that was finally diagnosed as parathyromatosis. We discuss the differential diagnosis of parathyromatosis from other parathyroid tumors, particularly from parathyroid carcinoma, which is important in the management of a suspected lesion.
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Affiliation(s)
- Ayşegül Aksoy-Altinboga
- Department of Pathology, Izmir Atatürk Training and Research Hospital, Yesilyurt, Izmir, Turkey
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20
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Tonelli F, Giudici F, Cavalli T, Brandi ML. Surgical approach in patients with hyperparathyroidism in multiple endocrine neoplasia type 1: total versus partial parathyroidectomy. Clinics (Sao Paulo) 2012; 67 Suppl 1:155-60. [PMID: 22584722 PMCID: PMC3328832 DOI: 10.6061/clinics/2012(sup01)26] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Usually, primary hyperparathyroidism is the first endocrinopathy to be diagnosed in patients with multiple endocrine neoplasia type 1, and is also the most common one. The timing of the surgery and strategy in multiple endocrine neoplasia type 1/hyperparathyroidism are still under debate. The aims of surgery are to: 1) correct hypercalcemia, thus preventing persistent or recurrent hyperparathyroidism; 2) avoid persistent hypoparathyroidism; and 3) facilitate the surgical treatment of possible recurrences. Currently, two types of surgical approach are indicated: 1) subtotal parathyroidectomy with removal of at least 3-3 K glands; and 2) total parathyroidectomy with grafting of autologous parathyroid tissue. Transcervical thymectomy must be performed with both of these procedures. Unsuccessful surgical treatment of hyperparathyroidism is more frequently observed in multiple endocrine neoplasia type 1 than in sporadic hyperparathyroidism. The recurrence rate is strongly influenced by: 1) the lack of a pre-operative multiple endocrine neoplasia type 1 diagnosis; 2) the surgeon's experience; 3) the timing of surgery; 4) the possibility of performing intra-operative confirmation (histologic examination, rapid parathyroid hormone assay) of the curative potential of the surgical procedure; and, 5) the surgical strategy. Persistent hyperparathyroidism seems to be more frequent after subtotal parathyroidectomy than after total parathyroidectomy with autologous graft of parathyroid tissue. Conversely, recurrent hyperparathyroidism has a similar frequency in the two surgical strategies. To plan further operations, it is very helpful to know all the available data about previous surgery and to undertake accurate identification of the site of recurrence.
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Affiliation(s)
- Francesco Tonelli
- Surgical Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy.
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21
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Vulpio C, D'Errico G, Mattoli MV, Bossola M, Lodoli C, Fadda G, Bruno I, Giordano A, Castagneto M. Recurrent renal hyperparathyroidism due to parathyromatosis. Clin Kidney J 2011; 4:318-20. [PMID: 25984178 PMCID: PMC4421719 DOI: 10.1093/ndtplus/sfr075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 05/26/2011] [Indexed: 11/14/2022] Open
Abstract
Parathyromatosis is the most severe type of recurrent secondary hyperparathyroidism (SHPT) after parathyroidectomy (PTX) in haemodialysis patients. It is difficult to completely remove all foci of parathyroid tissue and neck re-explorations are often required. Here, we report for the first time a case of recurrent SHPT due to parathyromatosis treated by radio-guided PTX. A haemodialysed 48-year-old woman with recurrent SHPT due to parathyromatosis was treated by radio-guided PTX. Preoperatively Ultrasonography, 99Tc-SestaMIBI scintigraphy and magnetic resonances of the neck and thorax were performed. The preoperative imaging techniques detected four parathyroid nodules, while intraoperative gamma probe identified six nodules (three in atypical site). No frozen sections were performed during surgery. Post-operative intact parathyroid hormone levels were stabilized in the range 300–500 pg/mL during the 26 month follow-up by means of cinacalcet and paricalcitol therapy. In cases of parathyromatosis, the preoperative imaging techniques are inadequate, while intraoperative gamma probe is useful to detect the parathyroid tissue and allows a more extensive cytoreduction because it ensures the removal of undetectable and ectopic parathyroid foci. The operative time is reduced and frozen sections are unnecessary. However, the radio-guided PTX do not rule out parathyromatosis recurrence and complementary medical treatment is appropriate.
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Affiliation(s)
- Carlo Vulpio
- Istituto Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Giovanni D'Errico
- Istituto di Medicina Nucleare, Università Cattolica del Sacro Cuore, Roma, Italia
| | | | - Maurizio Bossola
- Istituto Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Claudio Lodoli
- Istituto Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Guido Fadda
- Istituto di Anatomia Patologica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Isabella Bruno
- Istituto di Medicina Nucleare, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Alessandro Giordano
- Istituto di Medicina Nucleare, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Marco Castagneto
- Istituto Clinica Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
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22
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Removal of autografted parathyroid tissue for recurrent renal hyperparathyroidism in hemodialysis patients. World J Surg 2010; 34:1312-7. [PMID: 20130870 DOI: 10.1007/s00268-010-0412-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recurrent renal hyperparathyroidism (HPT) is a serious problem after parathyroidectomy (PTx). We evaluated the frequency of graft-dependent recurrent HPT and the clinical outcomes after removal of the autograft. METHODS Between March 1980 and January 2009, 2660 patients underwent total PTx with forearm autograft. After resection of all parathyroid glands, 30 pieces of 1 x 1 x 3 mm parathyroid tissue from diffuse hyperplasia, if possible, were autografted into brachioradial muscle. Graft-dependent recurrence of HPT was diagnosed by a high PTH gradient and detection of swollen autografts by palpation and/or MRI or US. RESULTS In 248/2660 (9.3%) patients, removal of the graft was required a total of 327 times (53 patients required removal of the autograft several times). The cumulative frequency of graft-dependent recurrent HPT was 17.4% ten years after the initial PTx. Thirty-two patients underwent both resection of missed glands located in the neck or mediastinum and removal of the graft. En-bloc resection of autograft with surrounding muscle was required to avoid reoperation. When the intact PTH level dropped under 300 pg/ml, in the majority of patients renal HPT could be medically managed after the operation. The mean weight of the resected parathyroid tissue was 1583.7 mg. No specimen had histopathologically malignant features. Three patients suffered from hematoma in the wound. CONCLUSIONS Graft-dependent recurrent renal HPT is not negligible. However, in the majority of patients, renal HPT can be controlled by removal of the autograft noninvasively. Total PTx with forearm autograft is preferable for hemodialysis patients, especially when long-term survival is expected.
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23
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Affiliation(s)
- Wen T Shen
- Department of Surgery, Section of Endocrine Surgery, Mt. Zion Medical Center, University Of California San Francisco, Hellman Bldg. Room C-349, Campus Box 1674, San Francisco, CA 94115, USA.
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24
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Parathyroid scintigraphy findings in chronic kidney disease patients with recurrent hyperparathyroidism. Eur J Nucl Med Mol Imaging 2009; 37:623-34. [DOI: 10.1007/s00259-009-1313-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Accepted: 10/21/2009] [Indexed: 10/20/2022]
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25
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Tonelli F, Marcucci T, Giudici F, Falchetti A, Brandi ML. Surgical approach in hereditary hyperparathyroidism. Endocr J 2009; 56:827-41. [PMID: 19797826 DOI: 10.1507/endocrj.k09e-204] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Francesco Tonelli
- Surgical Unit, Department of Clinical Physiopathology, and Regional Center for Hereditary Endocrine Tumors, University of Florence, Florence, Italy
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26
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Matsuoka S, Tominaga Y, Sato T, Uno N, Hiramitu T, Goto N, Nagasaka T, Uchida K. Relationship Between the Dimension of Parathyroid Glands Estimated by Ultrasonography and the Hyperplastic Pattern in Patients With Renal Hyperparathyroidism. Ther Apher Dial 2008; 12:391-5. [DOI: 10.1111/j.1744-9987.2008.00615.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Tominaga Y, Matsuoka S, Uno N, Sato T. Parathyroidectomy for Secondary Hyperparathyroidism in the Era of Calcimimetics. Ther Apher Dial 2008; 12 Suppl 1:S21-6. [DOI: 10.1111/j.1744-9987.2008.00627.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Eriguchi R, Umakoshi J, Tominaga Y, Sato Y. Successful treatment of inoperable recurrent secondary hyperparathyroidism with cinacalcet HCl. NDT Plus 2008; 1:218-220. [PMID: 19461861 PMCID: PMC2640318 DOI: 10.1093/ndtplus/sfn058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 04/28/2008] [Indexed: 11/21/2022] Open
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29
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Expression of Parafibromin in Distant Metastatic Parathyroid Tumors in Patients with Advanced Secondary Hyperparathyroidism Due to Chronic Kidney Disease. World J Surg 2008; 32:815-21. [DOI: 10.1007/s00268-007-9458-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Matsuoka S, Tominaga Y, Sato T, Uno N, Goto N, Katayama A, Uchida K, Takami H. QuiCk-IntraOperative Bio-Intact PTH assay at parathyroidectomy for secondary hyperparathyroidism. World J Surg 2007; 31:824-31. [PMID: 17354020 DOI: 10.1007/s00268-006-0601-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In uremic patients, metabolism of 1-84 parathyroid hormone (PTH) and fragments are delayed, and in these patients, the usefulness of intraoperative PTH assay may be problematic. We evaluated the usefulness of the QuiCk-IntraOperative Bio-Intact PTH (QPTH) assay for uremic patients with secondary hyperparathyroidism who required total parathyroidectomy (PTx) with forearm autograft. The purpose of our study was to recognize whether QPTH in uremic patients was useful to determine during operation whether complete PTx had been achieved. METHODS Forty-four patients who underwent initial PTx were enrolled in this study. Blood samples were drawn just after induction of general anesthesia (basal samples), immediately after removal of the last gland, and at 5, 10, 15, and 30 minutes, and at the first morning after PTx. The assay was performed immediately after sample collection. Reductions of PTH levels were evaluated and expressed in percentage of basal levels. RESULTS The mean PTH levels in 41 patients, excluding 3 in whom the PTH level did not drop significantly (>60 pg/ml), measured by QPTH at anesthesia, 0, 5, 10, 15, and 30 minutes were 734.3, 104.7, 58.8, 37.4, 27.0, 16.3 pg/ml, corresponding to 100%, 17.1%, 9.3%, 5.8%, 4.1%, 2.4% of the preexcision values, respectively. If the cutoff value was defined as 10.8% at 10 minutes, the sensitivity was 100% and specificity 90%. When the QPTH level dropped to under 10.8% at 10 minutes, we could consider that all glands were removed. CONCLUSIONS QPTH in uremic patients is very useful to determine whether complete PTx is achieved during operation.
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Affiliation(s)
- Susumu Matsuoka
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
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31
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Tublin ME, Yim JH, Carty SE. Recurrent hyperparathyroidism secondary to parathyromatosis: clinical and imaging findings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:847-51. [PMID: 17526617 DOI: 10.7863/jum.2007.26.6.847] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Parathyromatosis, a condition in which hyperfunctioning parathyroid tissue is distributed throughout the neck, is a rare but challenging cause of recurrent hyperparathyroidism after parathyroidectomy. The purpose of this series is to describe the imaging appearance of parathyromatosis and the potential utility of sonographic localization before resection. METHODS Imaging is routinely performed in an attempt to identify autonomous residual parathyroid glands in patients with recurrent hyperparathyroidism after parathyroidectomy. The sonographic and technetium Tc 99m sestamibi studies and the clinical records of 2 patients with recurrent hyperparathyroidism secondary to parathyromatosis were reviewed. RESULTS Color Doppler sonography easily identified scattered deep and superficial hypoechoic, hypervascular cervical nodules that did not conform to typical anatomic locations of parathyroid glands; the nodules corresponded to areas of delayed tracer uptake at Tc 99m sestamibi single-photon emission computed tomography. Intraoperative mapping of nodules aided the successful resection of widespread parathyromatosis in 1 patient. CONCLUSIONS Although the sonographic appearance of parathyromatosis may mimic disseminated cervical malignancy, a confident diagnosis of this rare entity may be made in the appropriate clinical setting. Sonography may also aid in directing the resection of disseminated parathyroid tissue in selected patients.
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Affiliation(s)
- Mitchell E Tublin
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213 USA.
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