Parathyroid surgery without instant PTH or radioguided Sestamibi scan.

BACKGROUND: Radioguided Sestamibi scan and instant PTH (iPTH) are being used in minimally invasive parathyroid surgery (MIP). Experienced surgeons cure over 90-95% of the patients with primary hyperparathyroidism. PURPOSE/METHOD: To study the surgical results in treating hyperparathyroidism in a for profit community hospital lacking both iPTH and radioguided Sestamibi scan, we reviewed the patients operated from November 1, 2005 to October 31, 2006. RESULTS: The study comprised 56 patients: 52 with primary hyper-parathyroidism, three with secondary hyperparathyroidism and one with tertiary hyperparathyroidism. The only localizing test utilized pre-operatively was the Sestamibi Scan. PTH was measured immediately before and after surgery but the results was received seven to ten days later. The affected glands were removed in all patients. Fifty of 52 (96%) of the patients with primary hyperparathyroidism, the three patients with secondary hyper-parathyroidism and the patient with tertiary hyperparathyroidism are normocalcemic with normal PTH levels. Two patients have persistent mild hypercalcemia. Associated conditions were three papillary carcinoma of the thyroid, three multinodular goiter, four had a single thyroid nodule, one had an adrenal tumor and three were reoperations. CONCLUSION: Parathyroid surgery can be done safely and effectively in community hospitals without the utilization of radioguided Sestamibi scan and iPTH measurement.

History of parathyroid surgery in Puerto Rico

Review article that includes the worldwide history, as a reference for the readers, and the local history of hyperparathyroidism in Puerto Rico.

Parathyroid surgery without instant PTH or radioguided Sestamibi scan

BACKGROUND: Radioguided Sestamibi scan and instant PTH (iPTH) are being used in minimally invasive parathyroid surgery (MIP). Experienced surgeons cure over 90-95% of the patients with primary hyperparathyroidism. PURPOSE/METHOD: To study the surgical results in treating hyperparathyroidism in a for profit community hospital lacking both iPTH and radioguided Sestamibi scan, we reviewed the patients operated from November 1, 2005 to October 31, 2006. RESULTS: The study comprised 56 patients: 52 with primary hyper-parathyroidism, three with secondary hyperparathyroidism and one with tertiary hyperparathyroidism. The only localizing test utilized pre-operatively was the Sestamibi Scan. PTH was measured immediately before and after surgery but the results was received seven to ten days later. The affected glands were removed in all patients. Fifty of 52 (96%) of the patients with primary hyperparathyroidism, the three patients with secondary hyper-parathyroidism and the patient with tertiary hyperparathyroidism are normocalcemic with normal PTH levels. Two patients have persistent mild hypercalcemia. Associated conditions were three papillary carcinoma of the thyroid, three multinodular goiter, four had a single thyroid nodule, one had an adrenal tumor and three were reoperations. CONCLUSION: Parathyroid surgery can be done safely and effectively in community hospitals without the utilization of radioguided Sestamibi scan and iPTH measurement.

The surgical management of insulinoma

Insulinoma is the most common endocrine tumor of the pancreas. Over 90 of the insulinomas are benign and single, and can be cured by simple excision. Depending on the location, insulinomas can be enucleated, might require partial or distal pancreatectomy or pancreaticoduodenectomy. Five cases with insulinoma successfully treated by surgical intervention, two by enuclation, two by distal pancreatectomy and splenectomy, and preservation of the spleen have been summarized. The management of insulinoma involves the diagnosis, localization of the tumor and treatment. Insulinomas are rare tumors of the pancreas. Nevertheless, it is the most common endocrine tumor of the pancreas. Specifically arising from the beta cells, of the islets of Langerham, that produce insulin (fig.1). Its incidence is one in 250,000 inhabitants. It can be seen at any age, but is more frequent in females between 4 and 82 years of age, with a mean of 45.5 years. Insulinomas are evenly distributed between the head, body and tail of the pancreas. Over 90 are benign and single and can be cured by simple excision. Depending on the location insulinomas can be enucleated, might require partial or distal pancreatectomy or a pancreaticoduodenectomy. Ten percent could be malignant when metastasis to peripancreatic lymph nodes or to the liver is detected. The course of the patient with malignant insulinoma is an indolent one. The release of insulin leads to fasting hypoglycemia producing confusion, loss of consciousness, coma or convulsions. The hypoglycemia in turn can induce the release of cathecolamines producing tachycardia, tremulousness and diaphoresis. The Whipple's triad must be present for the diagnosis of insulinoma; symptoms of hypoglycemia, glucose level below 50 mgs/dl and relief of symptoms by the administration of glucose. In large series the interval between the onset of symptoms and a definitive diagnosis of insulinoma was 37 months, with a range of 0 to 14 years

Clinical profile of 128 subjects operated for primary hyperparathyroidism.

From 1960 to 1990, one hundred twenty eight (128) subjects with primary hyperparathyroidism were operated in the University Hospital. The medical records were reviewed. Serum and urine chemistries were done by conventional methods, serum PTH was done by RIA's (N-, C-, and midregion) and intact by IRMA and 1,25 dihydroxycholecalciferol by a non equilibrium receptor assay from calf thymus and preceded by double Sep-Pak chromatography. The distal third of the radius (nondominant arm) was used to evaluate radial bone density (RBD), using single photon absorptiometry (Norland) and the lumbar bone density (LBD) was measured by dual energy X Ray absorptiometry (DEXA). The RBD was done in 41 females and 15 males and the LBD in 12 females and 4 males. The series comprised 95 females, age range from 15 to 79 years, and 33 males, age range from 14 to 69 years. Prominent clinical features included nephrolithiasis in 72 subjects (56%), osteitis fibrosa cystica in 2, isolated familial hyperparathyroidism in 4 subjects in one family, 7 subjects with MEN-1 in 3 families, and 4 subjects with MEN-2 in one family. Only 7 subjects were asymptomatic. Serum calcium was elevated in all, serum alkaline phosphatase was elevated in 24% and urinary hydroxiproline was increased in 48%. Serum phosphorus was low in 92%. PTH assay was either elevated or inappropriately normal for the serum calcium in all patients tested. Serum 1,25 D was elevated in 57%. The PTH level was positively correlated with the serum calcium (r = 0.70), but had no significant correlation with the serum phosphorus and the 1,25 D. The RBD expressed as the standard deviation from that of the mean for age and sex matched controls was > or = 2 SD below the mean in 39% of females and in 40% of males. In contrast to the RBD none of the subjects tested had a LBD > or = 2 SD below the age and sex adjusted mean. 103 subjects had adenomas, 20 primary hyperplasia, 2 carcinomas and in 3 surgical exploration was unsuccessful. As to the outcome of Surgery, 117 (93%) were cured. Thus, in this series, successful surgery for primary hyperparathyroidism is the rule. Primary hyperparathroidism is rarely asymptomatic and appendicular bone disease and nephrolithiasis are commonly seen.

Parathyroid carcinoma: diagnosis and management.

A patient with severe hypercalcemia and a palpable neck mass is presented. The highest calcium was 18.8 mg/dL. A left lower neck mass was felt on examination. The trachea was deviated to the right side on a chest film. A barium swallow demonstrated an indentation on the left side of the esophagus. An en-bloc resection of the mass including the thyroid lobe, the strap muscles, and the recurrent laryngeal nerve was done. The pathologic specimen revealed parathyroid carcinoma with dense fibrous septae, invasion of the capsule, and vascular invasion. The patient is alive and without evidence of hypercalcemia or recurrence of the disease 23 years after surgery, probably the longest survivor with carcinoma of the parathyroid gland. Parathyroid carcinoma should be suspected in any patient with severe hypercalcemia and a palpable mass. The best chance for cure is obtained by performing a wide surgical excision during the initial operation.

Extra-adrenal pheochromocytoma

We have presented our experience in the diagnosis and management of three patients with extra-adrenal pheochromocytomas. Only two had hypertension, although all three had increased catecholamine production. The third patient was normotensive preoperatively and remained normotensive after the immediate postoperative period. Two patients are alive and without evidence of disease, the third patient died from what was considered to be a malignant pheochromocytoma. All three patients presented with palpable masses, confirmed by computerized tomography

Pheocromocytoma and gastrointestinal bleeding.

A 46-year-old patient who presented with an abdominal mass and gastrointestinal bleeding associated with an extra-adrenal pheochromocytoma is discussed. He had no history of hypertension. An ill-defined mass was felt at the upper abdomen. CT and arteriography confirmed the presence of a large mass with calcifications in the right paravertebral region. Upper endoscopy revealed multiple varices at the third portion of the duodenum. Abdominal exploration revealed a huge tumor at the root of the small bowel mesentery with multiple arterial and venous vessels entering the third portions of the duodenum. The tumor was unresectable. Biopsy demonstrated a pheochromocytoma. The patient developed pulmonary edema in the immediate postoperative course. He recovered and was discharged home on Dibenzyline. He has been readmitted on various occasions with gastrointestinal bleeding and congestive heart failure. Presently he is working and feels relatively well 5 years after the operation. A review of the literature for gastrointestinal complications of pheochromocytomas was done. There is a scarcity of reports of gastrointestinal bleeding associated with pheochromocytomas.

Extra-adrenal pheochromocytoma.

We have presented our experience in the diagnosis and management of three patients with extra-adrenal pheochromocytomas. Only two had hypertension, although all three had increased catecholamine production. The third patient was normotensive preoperatively and remained normotensive after the immediate postoperative period. Two patients are alive and without evidence of disease, the third patient died from what was considered to be a malignant pheochromocytoma. All three patients presented with palpable masses, confirmed by computerized tomography.

Unusual cases of hyperparathyroidism.

The history, physical and radiologic findings, treatment and pathology in five unusual cases of hyperparathyroidism is presented. The hyperparathyroidism was caused by a large (113 grams) mediastinal adenoma in the first patient, who is alive 25 years after surgery. A parathyroid carcinoma with compression of the esophagus was documented in the second patient. This patient is alive and normocalcemic 23 years after surgical treatment. A third patient with hyperplasia returned with hypercalcemia 20 years postsurgery requiring reoperation. A fourth patient with advanced bone findings was found to have a parathyroid adenoma. The fifth case is a patient with tertiary hyperparathyroidism secondary to hypophosphatemic rickets.

Surgical management of hyperparathyroidism. A 24 years experience

Our 24 years experience in the surgical treatment of 130 patients with primary hyperparathyroidism was presented. A single adenoma of the parathyroid glands was the predominant lesion. The lower parathyroid glands were more frequently the site of the adenoma, with the right lower gland presenting the highest incidence. The incidence of hyperplasia and carcinoma is similar to the reported literature. The offending glands were identified in the vast majority of the patients. The number of complications is significantly low with a zero surgical mortality. The utilization of preoperative localizing test is not recommended for the initial neck exploration. Satisfactory results can be obtained with a minimal work up

Hypertension secondary to adrenal tumors ten years experience

We have presented our ten years experience in the surgical management of adrenal tumors. Patients presenting with hypertension (9) are normotensive following the removal of the offending adrenal tumor. One patient had an extra-adrenal pheochromocytoma, one had a huge organized adrenal hematoma and one patient has a non-functional tumor. The diagnosis and management of endocrine tumors is a challenge to the clinician

Hypertension secondary to adrenal tumors ten years experience.

We have presented our ten years experience in the surgical management of adrenal tumors. Patients presenting with hypertension (9) are normotensive following the removal of the offending adrenal tumor. One patient had an extra-adrenal pheochromocytoma, one had a huge organized adrenal hematoma and one patient has a non-functional tumor. The diagnosis and management of endocrine tumors is a challenge to the clinician.

Surgical management of hyperparathyroidism. A 24 years experience.

Our 24 years experience in the surgical treatment of 130 patients with primary hyperparathyroidism was presented. A single adenoma of the parathyroid glands was the predominant lesion. The lower parathyroid glands were more frequently the site of the adenoma, with the right lower gland presenting the highest incidence. The incidence of hyperplasia and carcinoma is similar to the reported literature. The offending glands were identified in the vast majority of the patients. The number of complications is significantly low with a zero surgical mortality. The utilization of preoperative localizing test is not recommended for the initial neck exploration. Satisfactory results can be obtained with a minimal work up.

Pheochromocytoma: a twenty year experience at the University Hospital.

During the past 20 years (1970-90), we had 24 patients with pheochromocytoma: 19 diagnosed clinically and 5 post-mortem. Their ages ranged from 17 to 74 (mean, 43.2 years). Males (n = 14) outnumbered females (n = 10), a 1.41:1 M:F ratio. A majority were symptomatic (95%), with a typical triad of headaches, palpitations and diaphoresis. Most frequent finding was hypertension (95%). It was sustained in 60% and paroxysmal in 35%. In 6 patients (25%) pheochromocytomas were bilateral, all familial. Fifteen were solitary adrenal tumors (63%); 3 (12.5%) were extra-adrenal: 2 intra-abdominal, and 1 cardiac paraganglioma of right atrium. Of 6 familial cases, 4 were associated to Von Hippel-Lindau (VHL) disease, while 2 were multiple endocrine neoplasia (MEN-II) patients. All familial cases were bilateral and in the adrenals. There were no malignancies. Among the 19 clinical cases pre-operative Dx was made by positive urine VMA or catecholamines urine levels: (95 and 100% sensitivity respectively). Preoperative visualization by CT or MRI was done in 62% of the most recent patients. In 5 earlier cases the diagnosis was made post mortem: 3 died of cerebral hemorrhage, 1 with a pons infarct and 1 with congestive heart failure (CHF). There were 2 post-operative deaths and another died 13 years later from thyroid medullary carcinoma. Of the 19 operated, 13 (68%) were cured. Thus pheochromocytomas retain considerable morbidity and some mortality. These rare tumors constitute a clinical diagnostic challenge yet a rewarding therapeutic experience for the alert physician.