Normocalcemic primary hyperparathyroidism

ABSTRACT Normocalcemic primary hyperparathyroidism (PHPT) is a newer phenotype of PHPT defined by elevated PTH concentrations in the setting of normal serum calcium levels. It is increasingly being diagnosed in the setting of evaluation for nephrolithiasis or metabolic bone diseases. It is important to demonstrate that PTH values remain consistently elevated and to measure ionized calcium levels to make the diagnosis. A diagnosis of normocalcemic disease is one of exclusion of secondary forms of hyperparathyroidism, including vitamin D deficiency, renal failure, medications, malabsorption, and hypercalciuria. Lack of rigorous diagnostic criteria and selection bias of the studied populations may explain the different rates of bone and renal complications. The natural history still remains unknown. Caution should be used in recommending surgery, unless clearly indicated. Here we will review the diagnostic features, epidemiology, clinical presentation, natural history, medical and surgical management of normocalcemic PHPT.

Preoperative diagnosis and surgical strategies of primary hyperparathyroidism / 中华内分泌外科杂志

Objective To investigate the preoperative localizaion diagnosis and surgical strategies of primary hyperparathyroidism (pHPT).Methods The clinical data of pHPT patients who underwent initial parathyroid surgery at the Peking Union Medical College Hospital from Jan.2009 to Apr.2017 were retrospectively analyzed to explore preoperative localization and surgical options.Results There were a total of 902 surgical cases included in the study with 674 women and 228 men.All had preoperative parathyroid ultrasonography (US) (sensitivity 97.18％,positive predictive value (PPV) 98.40％) and 99Tcm-sestamibi (MIBI) scan (sensitivity 94.24％,PPV 98.00％).The combination of US and MIBI scan had a sensitivity of 92.39％ and PPV of 97.37％.MIBI scan showed negative results in 51 cases.We found that male patients with cystic lesions were more likely related to negative MIBI scan (P＜0.05).Among 89 patients with negative MIBI and/or US,39 received neck CT,17 received positron emission tomography (PET)/CT,and 9 received ultrasound-guided biopsy for further localization.800 patients (88.69％) underwent minimally invasive parathyroid surgery (MIP) with anesthesia of cervical plexus block.656 patients (72.72％) had normal parathyroid hormone (PTH) level on the first post-operative day,140 patients (15.52％) had postoperative hypocalcaemia and 234 patients (25.94％) presented hypocalcaemic symptoms within 3 days after operation,which could be relieved by intravenous calcium or continuous medicine taken by mouth.During the follow-up of the 800 MIP patients,4 had recurrence and one patient was not cured.Conclusions Parathyroid US and MIBI scan are of good value in localizaion diagnosis.Neck CT or PET/CT should be used as supplementary approaches in patients with negative US and/or MIBI scan.MIP with anesthesia of cervical plexus block is simple and feasiable for pHPT cases with accurate localization.

Cirugía paratiroidea radioguiada: experiencia inicial / Initial experience in radio-guided parathyroid surgery

Introducción: la gammagrafía con 99mTc-MIBI permite la localización preoperatoria no invasiva y facilita el acceso mínimamente invasivo en pacientes con hiperparatiroidismo primario (HPTP). Objetivos: describir los resultados iniciales de la gammagrafía paratiroidea con 99mTc-MIBI en pacientes con HPTP. Métodos: entre mayo de 2007 y febrero de 2010 fueron operados 10 pacientes por HPTP. Se excluyó una paciente con un síndrome de neoplasia endocrina múltiple. La edad media fue 46,3 años (32-70 años). Predominó el sexo femenino (6). Los síntomas principales fueron dolores óseos, debilidad, cefalea y cólico nefrítico. Un paciente presentaba tumores pardos múltiples. La enfermedad asociada más frecuente fue la hipertensión arterial. Los pacientes fueron seguidos entre 25 y 58 meses (promedio 45,3 meses). Resultados: uno de dos enfermos reintervenidos por HPTP persistente presentó hipoparatiroidismo posoperatorio (ambos tenían enfermedad tiroidea multinodular). De un total de 12 glándulas enfermas, 11 eran inferiores (9 izquierdas y 2 derechas) y una superior izquierda. La sensibilidad para la gammagrafía fue del 83 por ciento y la especificidad del 100 por ciento y, para la ecografía, estos valores fueron del 34,6 por ciento y del 96 por ciento, respectivamente. No hubo complicaciones ni muertes. Con un seguimiento promedio de 45,3 meses (25-58 meses), todos los pacientes se encontraban eucalcémicos. Conclusiones: La sensibilidad de la gammagrafía preoperatoria con 99mTc-MIBI permite obtener resultados satisfactorios en pacientes con HPTP tratados mediante técnicas de mínima invasión. Los pacientes con enfermedad nodular tiroidea deben ser evaluados cuidadosamente por el riesgo de falsos positivos(AU)

Introduction: 99mTc-MIBI scanning allows the non-invasive preoperative location and facilitates the minimally invasive access to patients with primary hyperparathyroidism. Objectives: to describe the initial results of 99mTc-MIBI parathyroid scanning in patients suffering primary hyperparathyroidism. Methods: from May 2007 through February 2010, ten patients with hyperparathyroidism were operated on. A female patient with multiple endocrine neoplasia syndrome was excluded from the study. The mean age was 46.3 years (32-70 years). Females predominated (6). The main symptoms were bone aches, weakness, headache and nephric colic. One patient presented with multiple brown tumors. The most common associated disease was blood hypertension. These patients were followed-up for 25 to 28 months (average 45.3 months). Results: one of the two patients undergoing resurgery for persistent hyperparathyroidism presented with hypoparathyroidsm posoperatively (both suffered multinodular thyroid disease). Of a total of 12 sick glands, 11 were lower glands (9 left and 2 right) and one upper left gland. The scanning sensitivity was 83percent and the specificity was 100 percent whereas the echography values were 34.6 percent and 96 percent, respectively. Neither complications nor deaths were observed. With the average follow-up of 45.3 months (25-28 months), all the patients were eucalcemic. Conclusions: preoperative 99mTc-MIBI scanning sensitivity allows achieving satisfactory results in patients with hyperparathyroidism and treated with minimally invasive techniques. The patients with nodular thyroid disease should be carefully evaluated due to positive false risk(AU)

Surgical Strategy in the Management of Primary Hyperparathyroidism

PURPOSE: The objective of this study was to evaluate the outcomes of parathyroid surgery, by comparing conventional and minimally invasive parathyroidectomy (MIP), and to present our strategy for the surgical treatment of primary hyperparathyroidism. METHODS: A retrospective study was performed for a 24-year period (1980~2003), on 119 surgically explored patients with primary hyperparathyroidism. RESULTS: Sixty one procedures were performed using a conventional cervical exploration and 58 patients had been selected for MIP, such as radio-guided parathyroidectomy (MIRP) or focused parathyroidectomy (MIFP). There were no significant differences in the age distribution, serum calcium, phosphate and intact PTH levels between the conventional and MIP groups. However, the operative times and lengths of hospital stay were significantly decreased in the MIP group (P<0.01). The success rate of a 99mTc sestamibi scan was 98.3 % (57/58) in the MIP group. The surgical success rate for the entire series was 96.6%, with no significant differences between the conventional and MIP groups. CONCLUSION: The following surgical strategy is suggested for the management of primary hyperparathyroidism. If the 99mTc sestamibi scan shows a single, intense focus of uptake, consistent with the ultrasonographic findings, then an MIFP is likely to be successful. If no area, or multiple areas, of increased uptake is seen on the 99mTc sestamibi scan, consistent with ultrasonographic findings, or if the abnormal lesions are seen only on ultrasonography, then a bilateral cervical exploration should be performed. If a single focus of uptake is seen only on the 99mTc sestamibi scan, or if the location of a single lesion on the 99mTc sestamibi scan and ultrasonography do not match, then a MIRP is likely to be successful.

Surgical Strategy in the Management of Primary Hyperparathyroidism

PURPOSE: The objective of this study was to evaluate the outcomes of parathyroid surgery, by comparing conventional and minimally invasive parathyroidectomy (MIP), and to present our strategy for the surgical treatment of primary hyperparathyroidism. METHODS: A retrospective study was performed for a 24-year period (1980~2003), on 119 surgically explored patients with primary hyperparathyroidism. RESULTS: Sixty one procedures were performed using a conventional cervical exploration and 58 patients had been selected for MIP, such as radio-guided parathyroidectomy (MIRP) or focused parathyroidectomy (MIFP). There were no significant differences in the age distribution, serum calcium, phosphate and intact PTH levels between the conventional and MIP groups. However, the operative times and lengths of hospital stay were significantly decreased in the MIP group (P<0.01). The success rate of a 99mTc sestamibi scan was 98.3 % (57/58) in the MIP group. The surgical success rate for the entire series was 96.6%, with no significant differences between the conventional and MIP groups. CONCLUSION: The following surgical strategy is suggested for the management of primary hyperparathyroidism. If the 99mTc sestamibi scan shows a single, intense focus of uptake, consistent with the ultrasonographic findings, then an MIFP is likely to be successful. If no area, or multiple areas, of increased uptake is seen on the 99mTc sestamibi scan, consistent with ultrasonographic findings, or if the abnormal lesions are seen only on ultrasonography, then a bilateral cervical exploration should be performed. If a single focus of uptake is seen only on the 99mTc sestamibi scan, or if the location of a single lesion on the 99mTc sestamibi scan and ultrasonography do not match, then a MIRP is likely to be successful.