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Del Rio P, Boniardi M, De Pasquale L, Docimo G, Iacobone M, Materazzi G, Medas F, Minuto M, Mullineris B, Polistena A, Raffaelli M, Calò PG. Management of surgical diseases of Primary Hyperparathyroidism: indications of the United Italian Society of Endocrine Surgery (SIUEC). Updates Surg 2024; 76:743-755. [PMID: 38622315 PMCID: PMC11130045 DOI: 10.1007/s13304-024-01796-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/25/2024] [Indexed: 04/17/2024]
Abstract
A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in parathyroid surgery published in 2014, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 12 members of the SIUEC highly trained and experienced in thyroid and parathyroid surgery. The main topics concern diagnostic test and localization studies, mode of admission and waiting time, therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications), hospital discharge and patient information, outpatient care and follow-up, outpatient initial management of patients with pHPT.
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Affiliation(s)
- Paolo Del Rio
- Unit of General Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Boniardi
- Endocrine Surgery Unit, Department of General Oncology and Mini-Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Loredana De Pasquale
- Thyroid and Parathyroid Unit, Otolaryngology Unit, Department of Health Sciences, ASST Santi Paolo E Carlo, Università Degli Studi Di Milano, Milan, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Docimo
- Division of Thyroid Surgery, University of Campania "L. Vanvitelli", Naples, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padua, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Materazzi
- Endocrine Surgery Unit, University Hospital of Pisa, Pisa, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Minuto
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Barbara Mullineris
- Unit of General Surgery, Emergency and New Technologies, Modena Hospital, 41126, Modena, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Polistena
- Department of Surgery, University of Rome Sapienza, Policlinico Umberto I, Rome, Italy.
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Marco Raffaelli
- Centro Dipartimentale Di Chirurgia Endocrina E Dell'Obesità, U.O.C. Chirurgia Endocrina E Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
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DeLellis RA, Mangray S. Heritable forms of primary hyperparathyroidism: a current perspective. Histopathology 2017; 72:117-132. [DOI: 10.1111/his.13306] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Ronald A DeLellis
- Rhode Island Hospital and Alpert School of Medicine of Brown University; Providence RI USA
| | - Shamlal Mangray
- Rhode Island Hospital and Alpert School of Medicine of Brown University; Providence RI USA
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Samson S, Jego A, Kadri N, Doucet J, Zulfiqar AA. [Not Available]. SOINS. GERONTOLOGIE 2017; 22:45-46. [PMID: 28917337 DOI: 10.1016/j.sger.2017.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Ségolène Samson
- Département de médecine Interne-Gériatrie-Thérapeutique, CHU de Rouen, Hôpital Saint-Julien, 76140 Le Petit Quevilly, France
| | - Alain Jego
- Département de médecine Interne-Gériatrie-Thérapeutique, CHU de Rouen, Hôpital Saint-Julien, 76140 Le Petit Quevilly, France
| | - Nadir Kadri
- Département de médecine Interne-Gériatrie-Thérapeutique, CHU de Rouen, Hôpital Saint-Julien, 76140 Le Petit Quevilly, France
| | - Jean Doucet
- Département de médecine Interne-Gériatrie-Thérapeutique, CHU de Rouen, Hôpital Saint-Julien, 76140 Le Petit Quevilly, France
| | - Abrar-Ahmad Zulfiqar
- Département de médecine Interne-Gériatrie-Thérapeutique, CHU de Rouen, Hôpital Saint-Julien, 76140 Le Petit Quevilly, France.
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Guan B, Welch JM, Vemulapalli M, Li Y, Ling H, Kebebew E, Simonds WF, Marx SJ, Agarwal SK. Ethnicity of Patients With Germline GCM2-Activating Variants and Primary Hyperparathyroidism. J Endocr Soc 2017; 1:488-499. [PMID: 29264504 PMCID: PMC5686704 DOI: 10.1210/js.2017-00043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 03/20/2017] [Indexed: 01/11/2023] Open
Abstract
Context: Germline gain-of-function variants in the transcription factor GCM2 were found in 18% of kindreds with familial isolated hyperparathyroidism (FIHP). These variants [c.1136T>A (p.Leu379Gln) and c.1181A>C (p.Tyr394Ser)] were located in a 17-amino acid transcriptional inhibitory domain named C-terminal conserved inhibitory domain (CCID). Objective: We investigated the ethnicity of individuals with germline variants in the GCM2 CCID in our primary hyperparathyroidism (PHPT) patient samples and in the Genome Aggregation Database. Design: Ethnicity information was obtained from an in-house clinical database and genetic counseling. Sanger sequencing of blood DNA was used to determine the genotype of the GCM2 CCID region. Luciferase reporter assays were performed to determine the functional impact of GCM2 variants. Setting and Patients: National Institute of Diabetes and Digestive and Kidney Diseases endocrine clinic is a service that accepts PHPT referral patients. Results: The GCM2 p.Tyr394Ser variant was found in 41% [95% confidence interval (CI), 22% to 64%] of Ashkenazi Jewish (AJ) kindreds with FIHP and in 27% (95% CI, 17% to 40%) of AJ patients with sporadic PHPT. The p.Tyr394Ser variant was also found in sporadic PHPT patients of European ancestry, but at a lower prevalence. The p.Leu379Gln variant was found in 8% (95% CI, 1% to 26%) of European kindreds with FIHP and 0.5% (95% CI, 0% to 3.0%) of sporadic PHPT cases of European ancestry. The sporadic PHPT patients with GCM2-activating variants often had multigland involvement or postoperative recurrent or persistent disease. Conclusions: Specific GCM2-activating variants enriched among various ethnic backgrounds could contribute to a large number of cases with FIHP or sporadic PHPT.
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Affiliation(s)
- Bin Guan
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892
| | - James M Welch
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892
| | | | - Yulong Li
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892
| | - Hua Ling
- The Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland 21224
| | | | - William F Simonds
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892
| | - Stephen J Marx
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892.,The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20892
| | - Sunita K Agarwal
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892
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Guan B, Welch JM, Sapp JC, Ling H, Li Y, Johnston JJ, Kebebew E, Biesecker LG, Simonds WF, Marx SJ, Agarwal SK. GCM2-Activating Mutations in Familial Isolated Hyperparathyroidism. Am J Hum Genet 2016; 99:1034-1044. [PMID: 27745835 DOI: 10.1016/j.ajhg.2016.08.018] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/29/2016] [Indexed: 02/05/2023] Open
Abstract
Primary hyperparathyroidism (PHPT) is a common endocrine disease characterized by parathyroid hormone excess and hypercalcemia and caused by hypersecreting parathyroid glands. Familial PHPT occurs in an isolated nonsyndromal form, termed familial isolated hyperparathyroidism (FIHP), or as part of a syndrome, such as multiple endocrine neoplasia type 1 or hyperparathyroidism-jaw tumor syndrome. The specific genetic or other cause(s) of FIHP are unknown. We performed exome sequencing on germline DNA of eight index-case individuals from eight unrelated kindreds with FIHP. Selected rare variants were assessed for co-segregation in affected family members and screened for in an additional 32 kindreds with FIHP. In eight kindreds with FIHP, we identified three rare missense variants in GCM2, a gene encoding a transcription factor required for parathyroid development. Functional characterization of the GCM2 variants and deletion analyses revealed a small C-terminal conserved inhibitory domain (CCID) in GCM2. Two of the three rare variants were recurrent, located in the GCM2 CCID, and found in seven of the 40 (18%) kindreds with FIHP. These two rare variants acted as gain-of-function mutations that increased the transcriptional activity of GCM2, suggesting that GCM2 is a parathyroid proto-oncogene. Our results demonstrate that germline-activating mutations affecting the CCID of GCM2 can cause FIHP.
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Marcucci G, Cianferotti L, Beck-Peccoz P, Capezzone M, Cetani F, Colao A, Davì MV, degli Uberti E, Del Prato S, Elisei R, Faggiano A, Ferone D, Foresta C, Fugazzola L, Ghigo E, Giacchetti G, Giorgino F, Lenzi A, Malandrino P, Mannelli M, Marcocci C, Masi L, Pacini F, Opocher G, Radicioni A, Tonacchera M, Vigneri R, Zatelli MC, Brandi ML. Rare diseases in clinical endocrinology: a taxonomic classification system. J Endocrinol Invest 2015; 38:193-259. [PMID: 25376364 DOI: 10.1007/s40618-014-0202-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/17/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE Rare endocrine-metabolic diseases (REMD) represent an important area in the field of medicine and pharmacology. The rare diseases of interest to endocrinologists involve all fields of endocrinology, including rare diseases of the pituitary, thyroid and adrenal glands, paraganglia, ovary and testis, disorders of bone and mineral metabolism, energy and lipid metabolism, water metabolism, and syndromes with possible involvement of multiple endocrine glands, and neuroendocrine tumors. Taking advantage of the constitution of a study group on REMD within the Italian Society of Endocrinology, consisting of basic and clinical scientists, a document on the taxonomy of REMD has been produced. METHODS AND RESULTS This document has been designed to include mainly REMD manifesting or persisting into adulthood. The taxonomy of REMD of the adult comprises a total of 166 main disorders, 338 including all variants and subtypes, described into 11 tables. CONCLUSIONS This report provides a complete taxonomy to classify REMD of the adult. In the future, the creation of registries of rare endocrine diseases to collect data on cohorts of patients and the development of common and standardized diagnostic and therapeutic pathways for each rare endocrine disease is advisable. This will help planning and performing intervention studies in larger groups of patients to prove the efficacy, effectiveness, and safety of a specific treatment.
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Affiliation(s)
- G Marcucci
- Head, Bone Metablic Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
| | - L Cianferotti
- Head, Bone Metablic Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - P Beck-Peccoz
- Department of Clinical Sciences and Community Health, University of Milan and Endocrine Unit, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - M Capezzone
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Endocrinology and Metabolism and Biochemistry, University of Siena, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - F Cetani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Colao
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Naples, Italy
| | - M V Davì
- Section D, Department of Medicine, Clinic of Internal Medicine, University of Verona, Verona, Italy
| | - E degli Uberti
- Section of Endocrinology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - S Del Prato
- Section of Metabolic Diseases and Diabetes, Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy
| | - R Elisei
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Faggiano
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Naples, Italy
| | - D Ferone
- Endocrinology, Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - C Foresta
- Department of Medicine and Centre for Human Reproduction Pathology, University of Padova, Padua, Italy
| | - L Fugazzola
- Department of Clinical Sciences and Community Health, University of Milan and Endocrine Unit, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - E Ghigo
- Division of Endocrinology, Diabetology and Metabolism Department of Medical Sciences, University Hospital Città Salute e Scienza, Turin, Italy
| | - G Giacchetti
- Division of Endocrinology, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Umberto I-GM Lancisi-G Salesi, Università Politecnica delle Marche, Ancona, Italy
| | - F Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - A Lenzi
- Chair of Endocrinology, Section Medical Pathophysiology, Food Science and Endocrinology, Department Exp. Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - P Malandrino
- Endocrinology, Department of Clinical and Molecular Biomedicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - M Mannelli
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - C Marcocci
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy
| | - L Masi
- Department of Orthopedic, Metabolic Bone Diseases Unit AOUC-Careggi Hospital, Largo Palagi, 1, Florence, Italy
| | - F Pacini
- Section of Endocrinology and Metabolism, University of Siena, Siena, Italy
| | - G Opocher
- Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padua, Italy
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - A Radicioni
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - M Tonacchera
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - R Vigneri
- Department of Clinical and Molecular Biomedicine, University of Catania, and Humanitas Catania Center of Oncology, Catania, Italy
| | - M C Zatelli
- Section of Endocrinology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M L Brandi
- Head, Bone Metablic Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
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Rosato L, Raffaelli M, Bellantone R, Pontecorvi A, Avenia N, Boniardi M, Brandi ML, Cetani F, Chiofalo MG, Conzo G, De Palma M, Gasparri G, Giordano A, Innaro N, Leopaldi E, Mariani G, Marcocci C, Marini P, Miccoli P, Nasi P, Pacini F, Paragliola R, Pelizzo MR, Testini M, De Toma G. Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery: II Consensus Conference of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB). J Endocrinol Invest 2014; 37:149-65. [PMID: 24497214 DOI: 10.1007/s40618-013-0022-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 11/16/2013] [Indexed: 02/08/2023]
Abstract
AIM To update the Diagnostic-Therapeutic-Healthcare Protocol (Protocollo Diagnostico-Terapeutico-Assistenziale, PDTA) created by the U.E.C. CLUB (Association of the Italian Endocrine Surgery Units) during the I Consensus Conference in 2008. METHODS In the preliminary phase, the II Consensus involved a selected group of experts; the elaboration phase was conducted via e-mail among all members; the conclusion phase took place during the X National Congress of the U.E.C. CLUB. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. CONCLUSIONS The PDTA for parathyroid surgery approved by the II Consensus Conference (June 2013) is the official PDTA of the U.E.C. CLUB.
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Affiliation(s)
- L Rosato
- Department of Surgery, ASL TO/4 Ivrea Hospital (TO), Piazza della Credenza, 2, 10015, IVREA, TO, Italy,
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Successful treatment of osteitis fibrosa cystica from primary hyperparathyroidism. Case Rep Orthop 2012; 2012:145760. [PMID: 23259108 PMCID: PMC3504233 DOI: 10.1155/2012/145760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 07/26/2012] [Indexed: 11/29/2022] Open
Abstract
Osteitis Fibrosa Cystica (OFC) is defined as the classic skeletal manifestation of advanced primary hyperparathyroidism. With the increased detection by means of routine calcium screening, the clinical profile of primary hyperparathyroidism in Western countries has shifted from symptomatic disease to one with subtle or no specific symptoms (“asymptomatic” primary hyperparathyroidism). The authors describe a classical feature of advanced primary hyperparathyroidism due to a parathyroid adenoma and its successful treatment.
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Syro LV, Scheithauer BW, Kovacs K, Toledo RA, Londoño FJ, Ortiz LD, Rotondo F, Horvath E, Uribe H. Pituitary tumors in patients with MEN1 syndrome. Clinics (Sao Paulo) 2012; 67 Suppl 1:43-8. [PMID: 22584705 PMCID: PMC3328811 DOI: 10.6061/clinics/2012(sup01)09] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
We briefly review the characteristics of pituitary tumors associated with multiple endocrine neoplasia type 1. Multiple endocrine neoplasia type 1 is an autosomal-dominant disorder most commonly characterized by tumors of the pituitary, parathyroid, endocrine-gastrointestinal tract, and pancreas. A MEDLINE search for all available publications regarding multiple endocrine neoplasia type 1 and pituitary adenomas was undertaken. The prevalence of pituitary tumors in multiple endocrine neoplasia type 1 may vary from 10% to 60% depending on the studied series, and such tumors may occur as the first clinical manifestation of multiple endocrine neoplasia type 1 in 25% of sporadic and 10% of familial cases. Patients were younger and the time between initial and subsequent multiple endocrine neoplasia type 1 endocrine lesions was significantly longer when pituitary disease was the initial manifestation of multiple endocrine neoplasia type 1. Tumors were larger and more invasive and clinical manifestations related to the size of the pituitary adenoma were significantly more frequent in patients with multiple endocrine neoplasia type 1 than in subjects with non-multiple endocrine neoplasia type 1. Normalization of pituitary hypersecretion was much less frequent in patients with multiple endocrine neoplasia type 1 than in subjects with non-multiple endocrine neoplasia type 1. Pituitary tumors in patients with multiple endocrine neoplasia type 1 syndrome tend to be larger, invasive and more symptomatic, and they tend to occur in younger patients when they are the initial presentation of multiple endocrine neoplasia type 1.
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Affiliation(s)
- Luis V Syro
- Department of Neurosurgery, Clinica Medellin, Hospital Pablo Tobon Uribe, Medellin, Colombia.
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Affiliation(s)
- Claudio Marcocci
- Department of Endocrinology and Metabolism, Section of Endocrinology and Bone Metabolism, University of Pisa, Pisa, Italy.
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