Hiperparatiroidismo primario y crisis hipercalcémica aguda tóxica / Primary hyperparathyroidism and acute toxic hypercalcaemic crisis

Objetivos: Describir las características clínicas y tratamiento quirúrgico de los pacientes con hipercalcemia aguda por hiperparatiroidismo primario (HPTP) y compararlas con las de otros pacientes con HPTP sin hipercalcemia aguda asociada. Material y métodos Estudio observacional prospectivo (1998-2010) sobre 158 pacientes con HPTP tratados mediante paratiroidectomía. Se identificaron aquellos con hipercalcemia aguda (>14mg/dl-3,5mmol/l- o >3mmol/l con síntomas de calciotoxicosis), se evaluaron sus características clínicas y terapéuticas y se compararon, mediante la U de Mann-Whitney y el test de Fisher, con los 146 pacientes con HPTP sin crisis hipercalcémicas. Resultados Doce pacientes (7,6%) presentaron hipercalcemia aguda con síntomas de calciotoxicosis y otros síntomas de cronicidad. Los valores preoperatorios de calcemia y PTH fueron 14,5±1,3mg/dl y 648,2±542pg/dl, respectivamente. Hubo 10 adenomas, una hiperplasia y un carcinoma. El peso medio de las piezas quirúrgicas fue 4.075±2.918 mg con un diámetro mayor de 27±14mm. Los gradientes de caída de PTH a los 10 y 25min fueron 79±18% y 92±6%. Las calcemias postoperatorias al alta y a los 6 meses fueron 8,2±0,7 y 9,1±0,9mg/dl. Las concentraciones plasmáticas de Ca, PTH y el peso y tamaño de las piezas quirúrgicas fueron mayores en los pacientes con crisis hipercalcémicas (p<0,001). No hubo diferencias en otros parámetros estudiados y en la tasa de curación. Conclusiones Las crisis hipercalcémicas fueron producidas por tumores más grandes, de mayor peso y que producían mayores concentraciones plasmáticas de Ca y PTH. Todos los pacientes presentaban síntomas de evolución crónica y la paratiroidectomía consiguió la curación (AU)

Objectives: To describe the clinical characteristics and surgical treatment of patients with acute hypercalcaemia due to primary hyperparathyroidism (PHPT) and compare them with other patients with PHPT without associated acute hypercalcaemia. Material and methods: A prospective, observational study (1998-2010) was conducted on 158patients with PHPT treated by parathyroidectomy. Those with acute hypercalcaemia(>14 mg/dl -3.5 mmol/L- or >3 mmol/L with symptoms of calcium toxicity) were evaluated by recording their clinical and treatment characteristics, and comparing them, using the Mann-Whitney U test and the Fisher test, with the 146 PHPT patients without hypercalcaemic crisis. Results: Twelve patients (7.6%) had acute hypercalcaemia with symptoms of calcium toxicity and other symptoms of chronicity. The preoperative calcium and PTH values were14.5 1.3 mg/dL and 648.2 542 pg/dL, respectively. There were 10 adenomas, 1 hyperplasia and 1 carcinoma. The mean weight of the surgical pieces was 4.075 2.918 mg, with a diameter greater than 27 14 mm. The gradients of PTH at 10 and 25 minutes were 79 18%and 92 6%, respectively. Post-operative calcium values on discharge and at 6 months were8.2 0.7 mg/dL and 9.1 0.9 mg/dL, respectively. The plasma concentrations of calcium, PTH, and the size of the surgical pieces were higher in patients with hypercalcaemic crisis(P<0.001). There were no differences in the other parameters studied or in the cure rate. Conclusions: Hypercalcaemic crises were caused by larger and heavier tumours that led to higher plasma Ca and PTH plasma concentrations. All patients had long-standing symptoms and parathyroidectomy led to cure of the disease (AU)

[Primary hyperparathyroidism and acute toxic hypercalcaemic crisis]. / Hiperparatiroidismo primario y crisis hipercalcémica aguda tóxica.

OBJECTIVES: To describe the clinical characteristics and surgical treatment of patients with acute hypercalcaemia due to primary hyperparathyroidism (PHPT) and compare them with other patients with PHPT without associated acute hypercalcaemia. MATERIAL AND METHODS: A prospective, observational study (1998-2010) was conducted on 158 patients with PHPT treated by parathyroidectomy. Those with acute hypercalcaemia (>14 mg/dl -3.5 mmol/L- or >3 mmol/L with symptoms of calcium toxicity) were evaluated by recording their clinical and treatment characteristics, and comparing them, using the Mann-Whitney U test and the Fisher test, with the 146 PHPT patients without hypercalcaemic crisis. RESULTS: Twelve patients (7.6%) had acute hypercalcaemia with symptoms of calcium toxicity and other symptoms of chronicity. The preoperative calcium and PTH values were 14.5 ± 1.3mg/dL and 648.2 ± 542 pg/dL, respectively. There were 10 adenomas, 1 hyperplasia and 1 carcinoma. The mean weight of the surgical pieces was 4.075 ± 2.918 mg, with a diameter greater than 27 ± 14 mm. The gradients of PTH at 10 and 25 minutes were 79 ± 18% and 92 ± 6%, respectively. Post-operative calcium values on discharge and at 6 months were 8.2 ± 0.7 mg/dL and 9.1 ± 0.9 mg/dL, respectively. The plasma concentrations of calcium, PTH, and the size of the surgical pieces were higher in patients with hypercalcaemic crisis (P<0.001). There were no differences in the other parameters studied or in the cure rate. CONCLUSIONS: Hypercalcaemic crises were caused by larger and heavier tumours that led to higher plasma Ca and PTH plasma concentrations. All patients had long-standing symptoms and parathyroidectomy led to cure of the disease.

Valor del diagnóstico topográfico preoperatorio en el hiperparatiroidismo / Value of preoperative topographic diagnosis in hyperparathyroidism

Objetivos: Definir la sensibilidad de la gammagrafía, la ecografía y la tomografía computarizada (TC) para el diagnóstico topográfico del hiperparatiroidismo. Comparar los resultados de 2 abordajes quirúrgicos distintos, diferenciados en función de los resultados obtenidos con estas pruebas. Estudiar la repercusión en la gestión clínica del proceso, analizando la relación beneficio/coste (valor). Pacientes y método: Estudio realizado en 87 pacientes afectados de hiperparatiroidismo (HPT) en 1996-2005. Para el diagnóstico topográfico se utilizaron la gammagrafía con 99Tc-sestamibi y la ecografía cervical en todos los pacientes, y la TC en 49 casos. La validación de las pruebas se hizo por la biopsia. Según los resultados se operó mediante 2 abordajes: a) cervicotomía exploradora (53 pacientes), y b) abordaje selectivo (34 pacientes). Se comparan las 2 series analizando los tiempos quirúrgicos (y de utilización de quirófano), la estancia media y el valor (eficiencia) del proceso, por el estudio de costes. Se utilizó la prueba de la X2 para comparar porcentajes y la t de Student para la comparación de medias, y se aceptó como significativo p < 0,001. Resultados: La gammagrafía fue positiva en el 89,7% de los pacientes. En todas las imágenes positivas solitarias el diagnóstico fue correcto. La sensibilidad de la ecografía fue del 56% y la de la TC, del 53%. La identificación de lesiones solitarias permitió efectuar un abordaje cervical selectivo. Cuando se compararon los resultados del abordaje selectivo con los de la cervicotomía exploradora, se constató una diferencia estadísticamente significativa (p < 0,001) a favor del abordaje selectivo, en los 3 parámetros que analizábamos: menos tiempo quirúrgico y de utilización del quirófano; menor estancia media, y menor costo total del proceso. El abordaje selectivo mejoró el valor de proceso. Conclusiones: La sensibilidad de la gammagrafía con 99Tc-sestamibi alcanzó el 89,7% y fue certera en el 100% de las lesiones solitarias captadoras. La de la ecografía fue del 56% y la de la TC, del 53%. El diagnóstico topográfico preoperatorio permite el abordaje cervical selectivo. Con un beneficio igual o mayor, el abordaje selectivo acorta significativamente el tiempo quirúrgico y de utilización del quirófano y la estancia media, y disminuye el coste del proceso. El cambio de estrategia quirúrgica hacia el abordaje selectivo, modulado por la utilización preoperatoria de estos recursos, mejora el valor (eficiencia) del proceso

Objectives: To define the sensitivity of scintigraphy, ultrasonography and computed tomography (CT) in the topographic diagnosis of hyperparathyroidism (HPT). To compare the results of two distinct surgical approaches, selected on the basis of the results of the tests. To study the effect of the above factors on the clinical management of the process by analyzing the cost/benefit ratio (value). Patients and method: This study was performed in 87 patients with HPT (1996-2005). For topographic diagnosis, 99Tc-sestamibi scintigraphy and cervical ultrasonography were used in all patients and CT was performed in 49 patients. The results of these tests were confirmed by biopsy. Depending on the results of these tests, two surgical approaches were used: a) exploratory cervicotomy (53 patients) and b) selective approach (34 patients). The two series were compared by analyzing surgical time (and operating room utilization), mean length of hospital stay, and Value (efficiency) of the process though cost analysis. The X2 test was used to compare percentages and Student's t-test was used to compare means. Statistical significance was set at p < 0.001. Results: Scintigraphy was positive in 89.7% of patients. In all positive solitary images, diagnosis was correct. The sensitivity of ultrasonography was 56% and that of CT was 53%. Identification of solitary lesions allowed a selective cervical approach to be used. When the results of the selective approach were compared with those of exploratory cervictomy, a statistically significant difference (p < 0.001) was found in favor of the selective approach in the three parameters analyzed: lower surgical time and operating room utilization, lower mean length of hospital stay, and lower total cost of the process. The selective approach improved the Value of the process. Conclusions: The sensitivity of 99Tc-sestamibi scintigraphy was 89.7% and this test was accurate in 100% of solitary lesions showing uptake. The sensitivity of ultrasonography was 56% and that of CT was 53%. Preoperative topographic diagnosis allows a selective cervical approach to be used. The selective approach produces an equal or greater benefit than exploratory cervicotomy and significantly shortens surgical time, operating room utilization, and mean length of stay, and reduces the cost of the process. The change in surgical strategy to the selective approach, modulated by preoperative utilization of these resources, improves the value (efficiency) of the process

[Utility of methoxy isobutyl isonitrile (MIBI) scintigraphy, ultrasound and computerized axial tomography in preoperative topographic diagnosis of hiperparathyroidism]. / Utilidad del MIBI, la ecografía y la tomografía computarizada en el diagnóstico topográfico preoperatorio del hiperparatiroidismo.

OBJECTIVES: 1. To assess the sensitivity of scintigraphy using methoxy isobutyl isonitrile (MIBI). 2. To compare its resolution with that of ultrasound (US) and computerized axial tomography (CAT). 3. To use its diagnostic reliability to determine whether selective approaches can be used to treat hyperparathyroidism (HPT). PATIENTS AND METHOD: A study of 76 patients who underwent surgery for HPT between 1996 and 2005 was performed. MIBI scintigraphy and cervical US were used for whole-body scanning in all patients; CAT was used in 47 patients. Intraoperative and postoperative biopsies were used for final evaluation of the tests, after visualization and surgical extirpation. RESULTS: The results of scintigraphy were positive in 65 patients (85.52%). The diagnosis was correct in all of the single images. Multiple images were due to hyperplasia and parathyroid adenomas with thyroid disease (5.2%). Three images, incorrectly classified as negative (3.94%), were positive. The sensitivity of US was 63% and allowed detection of three MIBI-negative adenomas (4%). CAT was less sensitive (55%), but detected a further three MIBI-negative adenomas (4%). CONCLUSIONS: 1. The sensitivity of MIBI reached 89.46%. In the absence of thyroid nodules, MIBI diagnosed 100% of single lesions. Pathological thyroid processes produced false-positive results (5.2%) and there were diagnostic errors (4%). 2. MIBI scintigraphy was more sensitive than US and CAT. 3. Positive, single image scintigraphy allows a selective cervical approach. US and CAT may help to save a further 8% of patients (with negative scintigraphy).

[Development and outcomes of the surgical management of multinodular goiter]. / Evolución y resultados en el manejo quirúrgico del bocio multinodular.

OBJECTIVES: The aims of this study were to: 1. Define our criteria and the results obtained in the surgical management of multinodular goiter (MNG); 2. Compare the results of partial thyroidectomies with those of total thyroidectomies; 3. Determine the incidence of "hidden" carcinomas diagnosed as MNG; 4. Define the most suitable treatment of MNG. MATERIAL AND METHODS: We performed a retrospective study (1999-2005) of 190 patients with MNG. Clinical characteristics, the diagnostic procedures used, surgical indications, the strategy employed, and biopsy results were analyzed. Overall morbidity and mortality were evaluated and statistical comparison of the morbidity-mortality rate between partial and total thyroidectomies was performed. RESULTS: Depending on the patients, diagnostic procedures consisted of ultrasonography, gammagraphy, computed tomography, and fine-needle aspiration (FNA). Surgical indication was established by compressive syndrome, endothoracic prolongation, rapid growth, suspected malignancy, nodular hyperthyroidism, the endocrinologist's criteria, and the patient's wishes. The surgical strategy showed a change in favor of radical surgery. The most common histologic diagnosis was nodular hyperplasia, but 16 carcinomas were "hidden" under a diagnosis of MNG (8.5%). There was no mortality. Morbidity, however, did exist, with the poorest results, showing statistically significant differences, occurring in total thyroidectomies. CONCLUSIONS: 1. Ultrasonography and FNA were routinely used for diagnosis. Surgical treatment tended to be radical. We believe that identification of recurrences and parathyroid disease is mandatory; 2. Morbidity was greater with total thyroidectomy; 3. Of patients who underwent surgery for MNG, 8.5% had a hidden thyroid carcinoma; 4. With certain limitations, total thyroidectomy is the most suitable therapy.

Evolución y resultados en el manejo quirúrgico del bocio multinodular / Development and outcomes of the surgical management of multinodular goiter

Objetivos. Los objetivos de nuestro estudio son: a) definir nuestros criterios y los resultados obtenidos en el manejo quirúrgico del bocio multinodular (BMN); b) comparar los resultados de las tiroidectomías parciales con los de la total; c) conocer la incidencia de carcinoma "oculto" bajo la apariencia de BMN, y d) establecer los patrones terapéuticos más idóneos del BMN. Material y métodos. Estudio retrospectivo, realizado en el período 1999-2005 con 190 pacientes afectos de BMN. Se estudian sus características clínicas, los recursos diagnósticos utilizados, la indicación quirúrgica, la estrategia seguida, los resultados de la biopsia y la morbimortalidad global y comparada, estadísticamente, entre las tiroidectomías parciales y las totales. Resultados. Como recursos diagnósticos se utilizaron la ecografía, la gammagrafía, la tomografía computarizada (TC) y la punción-aspiración con aguja fina (PAAF), según los casos. Las indicaciones quirúrgicas se establecieron por: síndrome compresivo, prolongación endotorácica, rápido crecimiento, sospecha de malignidad, hipertiroidismo nodular, criterio del endocrinólogo o voluntad del paciente. La estrategia quirúrgica mostró el cambio a favor de la cirugía radical. El diagnóstico histológico habitual fue la hiperplasia nodular, pero hubo un total de 16 carcinomas "ocultos" bajo el diagnóstico de BMN (8,50%). No hubo mortalidad, pero sí morbilidad, y se obtuvieron peores resultados, con diferencias estadísticamente significativas, en las tiroidectomías totales. Conclusiones. Presentamos las siguientes: a) para el diagnóstico, se usaron habitualmente la ecografía y la PAAF; en el tratamiento quirúrgico tendemos a la radicalidad y consideramos preceptivo identificar las recurrentes y paratiroides; b) la tiroidectomía total produjo más morbilidad; c) un 8,5% de los BMN operados ocultaban un carcinoma de tiroides, y d) la tiroidectomía total, con limitaciones, se aproxima a nuestro ideal terapéutico (AU)

Objectives. The aims of this study were to: 1. Define our criteria and the results obtained in the surgical management of multinodular goiter (MNG); 2. Compare the results of partial thyroidectomies with those of total thyroidectomies; 3. Determine the incidence of "hidden" carcinomas diagnosed as MNG; 4. Define the most suitable treatment of MNG. Material and methods. We performed a retrospective study (1999-2005) of 190 patients with MNG. Clinical characteristics, the diagnostic procedures used, surgical indications, the strategy employed, and biopsy results were analyzed. Overall morbidity and mortality were evaluated and statistical comparison of the morbidity-mortality rate between partial and total thyroidectomies was performed. Results. Depending on the patients, diagnostic procedures consisted of ultrasonography, gammagraphy, computed tomography, and fine-needle aspiration (FNA). Surgical indication was established by compressive syndrome, endothoracic prolongation, rapid growth, suspected malignancy, nodular hyperthyroidism, the endocrinologist's criteria, and the patient's wishes. The surgical strategy showed a change in favor of radical surgery. The most common histologic diagnosis was nodular hyperplasia, but 16 carcinomas were "hidden" under a diagnosis of MNG (8.5%). There was no mortality. Morbidity, however, did exist, with the poorest results, showing statistically significant differences, occurring in total thyroidectomies. Conclusions. 1. Ultrasonography and FNA were routinely used for diagnosis. Surgical treatment tended to be radical. We believe that identification of recurrences and parathyroid disease is mandatory; 2. Morbidity was greater with total thyroidectomy; 3. Of patients who underwent surgery for MNG, 8.5% had a hidden thyroid carcinoma; 4. With certain limitations, total thyroidectomy is the most suitable therapy (AU)