paratyroid disease

8/14/2019 Paratyroid Disease

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AnatomyAnatomy


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AnatomyAnatomy


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Anatomy / EmbryologyAnatomy / Embryology


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Parathyroid Anatomy and Histopathology:Parathyroid Anatomy and Histopathology:The Normal Parathyroid GlandThe Normal Parathyroid Gland

Supernumerary fifth parathyroid found betweenSupernumerary fifth parathyroid found between0.7%-5.8% patients0.7%-5.8% patients

55thth glands found in the mediastinum (thymus orglands found in the mediastinum (thymus orrelated to the aortic arch), thyrothymic tractrelated to the aortic arch), thyrothymic tract


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PATHOLOGYPATHOLOGY

HYPERPARATHYROIDISMHYPERPARATHYROIDISM

1 : 1,000 prevalence1 : 1,000 prevalence

F : M 2 : 1F : M 2 : 1

Usually mild / asymptomaticUsually mild / asymptomatic


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Histopathology of the Parathyroid GlandsHistopathology of the Parathyroid Glands

Parathyroid gland composed of chief cells, oxyphilic cellsParathyroid gland composed of chief cells, oxyphilic cellsand intermediate cellsand intermediate cells

Solitary parathyroid adenoma ~80%-85% of patients withSolitary parathyroid adenoma ~80%-85% of patients withprimary hyperparathyroidismprimary hyperparathyroidism

Variations in parathyroid adenoma includes otherVariations in parathyroid adenoma includes othersubtypes (oncocytic adenoma, lipoadenoma, large clearsubtypes (oncocytic adenoma, lipoadenoma, large clearcell adenoma, water-clear cell adenoma, and atypicalcell adenoma, water-clear cell adenoma, and atypicaladenoma).adenoma).


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Ob P1- parathyroid glands and the physiology of calcium hemostasis.Ob P1- parathyroid glands and the physiology of calcium hemostasis.

Synthesize and secret parathyroid hormone,Synthesize and secret parathyroid hormone,which along with vitamin D maintains calciumwhich along with vitamin D maintains calciumhemostasis.hemostasis.

Calcium PTH

Bone resorption,urine phosphorus

Renal resorption


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Ca++Ca++

Ca++Ca++

PTHPTH

1,25D1,25D

1,25D1,25D

--

--

ParathyroidsParathyroids

KidneyKidneyBoneBone

GI tractGI tract

Careabsorb

Careab

sorb


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Calcium MetabolismCalcium Metabolism

Intestine Bone kidney (2.1-2.6 mmol/l)Intestine Bone kidney (2.1-2.6 mmol/l) 97% of reservoir in bone, chronic regulation.97% of reservoir in bone, chronic regulation. Kidney involved in minute to minute flux.FiltersKidney involved in minute to minute flux.Filters

8000mg daily.8000mg daily. Net intestinal absorption is 200mg daily..Net intestinal absorption is 200mg daily.. If long term calcium losses exceed net calciumIf long term calcium losses exceed net calcium

absorption the deficit is resorbed from boneabsorption the deficit is resorbed from boneleading to demineralisation.leading to demineralisation.


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Calcium Metabolism - PTHCalcium Metabolism - PTH

Parathyroid Hormone (PTH), 84 AAParathyroid Hormone (PTH), 84 AAstructure. Secreted from parathyroid glandstructure. Secreted from parathyroid glandin response to hypocalcemia.in response to hypocalcemia.

Amino terminal (1-34 AA) contains theAmino terminal (1-34 AA) contains thebiological activity.biological activity.

PTH acts on receptors in target tissuesPTH acts on receptors in target tissues

leading to stimulation of adenylayeleading to stimulation of adenylayecyclase activity.cyclase activity.


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Calcium Metabolism- Vitamin DCalcium Metabolism- Vitamin D

Vitamin D formed in skin(D3 or cholecalciferol) by uvVitamin D formed in skin(D3 or cholecalciferol) by uv

light. Major source of vitamin D (90%). Also present inlight. Major source of vitamin D (90%). Also present indiet. This is the inert formdiet. This is the inert form Hydroxylated in the liver to 25-OH-VitD.Hydroxylated in the liver to 25-OH-VitD. Renal hydroxylation to 1,25 dihydroxy vitamin D (veryRenal hydroxylation to 1,25 dihydroxy vitamin D (very

active metabolite). Renal also produces 24,25 dihydroxyactive metabolite). Renal also produces 24,25 dihydroxyvit D. (inactive)vit D. (inactive) Calcium deficiency leads to 1,25 Dit D productionCalcium deficiency leads to 1,25 Dit D production 1,25 vit D acts on small intestine to increase calcium1,25 vit D acts on small intestine to increase calcium

absorption.absorption. Also acts on bone to cause resorption.Also acts on bone to cause resorption.


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Effects of PTHEffects of PTH

Increases calcium reabsorption by theIncreases calcium reabsorption by thekidney.kidney.

Decreases phosphate reabsorption by theDecreases phosphate reabsorption by thekidney.kidney.

Increases osteoclastic bone resorption.Increases osteoclastic bone resorption.


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Three forms of calcium in serumThree forms of calcium in serum

Ionised (physiological form).Ionised (physiological form). Protein-bound (50%), mainly to albuminProtein-bound (50%), mainly to albumin

Complexed to citrate and phosphate(1-Complexed to citrate and phosphate(1-2%).2%).


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Causes of HypercalcaemiaCauses of Hypercalcaemia

COMMON (97%) ofCOMMON (97%) of

all casesall cases

PrimaryPrimary

HyperparathyroidismHyperparathyroidism MalignancyMalignancy

LESS COMMONLESS COMMON

Familial benignFamilial benignhypercalcaemiahypercalcaemia

(FBH)(FBH) SarcoidosisSarcoidosis ThyrotoxicosisThyrotoxicosis

Vitamin D poisoningVitamin D poisoning Acute renal failureAcute renal failure


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Causes of Hypercalcemia-RARECauses of Hypercalcemia-RARE

ImmobilisationImmobilisation VIPomasVIPomas TuberculosisTuberculosis Milk-alkali syndromeMilk-alkali syndrome Addisons DiseaseAddisons Disease LithiumLithium Thiazide diureticsThiazide diuretics Parenteral feedingParenteral feeding


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List the causes, symptoms, and signs of hypercalcemia.List the causes, symptoms, and signs of hypercalcemia.

StonesStones NephrolithiasisNephrolithiasis

BonesBones Painful resorption of bonePainful resorption of bone Moans and Psychatric overtonesMoans and Psychatric overtones

Fatigue, depression, confusionFatigue, depression, confusion Abdominal groansAbdominal groans

Peptic ulcer and pancreatitisPeptic ulcer and pancreatitis


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SymptomsSymptoms

Tiredness and lethargyTiredness and lethargy Proximal muscle weaknessProximal muscle weakness

Polyuria, nocturia and thirstPolyuria, nocturia and thirst Nausea Vomiting and constipationNausea Vomiting and constipation Depression, psychosis and impairedDepression, psychosis and impaired

consciousness.consciousness.


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SIGNS AND SYMPTOMSSIGNS AND SYMPTOMSOF HYPERCALCEMIAOF HYPERCALCEMIA

CNSCNS

Lethargy, drowsinessLethargy, drowsiness

DepressionDepression

PsychosisPsychosis

Stupor, comaStupor, coma

NeuromuscularNeuromuscular

WeaknessWeakness

Proximal muscle weaknessProximal muscle weakness

HypotoniaHypotonia


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SIGNS ANDSIGNS ANDSYMPTOMSSYMPTOMSOFOF

HYPERCALCEMIAHYPERCALCEMIA

CardiovascularCardiovascular HTNHTN

ArrhythmiaArrhythmia Short QTShort QT

RenalRenal

Polyuria and polydipsiaPolyuria and polydipsiavolume depletionvolume depletion

Renal stonesRenal stones

NephrocalcinosisNephrocalcinosis


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SIGNS AND SYMPTOMS OFSIGNS AND SYMPTOMS OFHYPERCALCEMIAHYPERCALCEMIA

MusculoskeletalMusculoskeletal

Myalgias and arthralgiasMyalgias and arthralgias Metastatic calcificationsMetastatic calcifications

Ca-PO4 product > 70Ca-PO4 product > 70

BoneBone Osteitis fibrosis cysticaOsteitis fibrosis cystica OsteoporosisOsteoporosis FractureFracture


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SIGNS AND SYMPTOMSSIGNS AND SYMPTOMSOF HYPERCALCEMIAOF HYPERCALCEMIA

GI tractGI tractConstipationConstipation

Anorexia, N/VAnorexia, N/V

Dyspepsia, PUDDyspepsia, PUD

PancreatitisPancreatitis


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Know the difference between 1, 2, 4Know the difference between 1, 2, 4hyperparathyroidism.hyperparathyroidism.

PrimaryPrimary HyperparathyroidismHyperparathyroidismPTH calcium (normal renal function)PTH calcium (normal renal function)83% parathyroid adenoma, 15% parathyroid83% parathyroid adenoma, 15% parathyroid

hyperplasia, carcinoma ishyperplasia, carcinoma is rarerare 1-2%1-2% SecondarySecondary HyperparathyroidismHyperparathyroidism

poor renal functionpoor renal function calcium, POcalcium, PO44 PTHPTH

normal Canormal Ca TertiaryTertiary HyperparathyroidismHyperparathyroidism

Hyperplastic parathyroids from chronicHyperplastic parathyroids from chronicstimulation continue post renal transplantstimulation continue post renal transplant


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Primary HPTPrimary HPT

500 cases/million500 cases/million More common in femalesMore common in females

Incidence increases with ageIncidence increases with age Autonomous production of PTHAutonomous production of PTH Benign AdenomaBenign Adenoma

Asymptomatic pick-up.Asymptomatic pick-up.


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Hyperparathyroidism in other syndromesHyperparathyroidism in other syndromes(RARE)(RARE)

MEN Type 1 (Parathyroid adenoma, PituitaryMEN Type 1 (Parathyroid adenoma, Pituitaryadenoma, and pancreatic islet cell tumours).adenoma, and pancreatic islet cell tumours).

MEN Type 2 (Parathyroid adenoma, medullaryMEN Type 2 (Parathyroid adenoma, medullary

thyroid carcinoma and phaeochromocytoma)thyroid carcinoma and phaeochromocytoma)


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Discuss ddx of a paitent with hypercalcemia.Discuss ddx of a paitent with hypercalcemia.

HyperparathyroidismHyperparathyroidism MalignancyMalignancy

HematologicHematologic PTHrP producerPTHrP producer

HyperthyroidsmHyperthyroidsm Multiple myelomaMultiple myeloma

SarcoidosisSarcoidosis Milk-alkili syndromeMilk-alkili syndrome Vit D or A intoxicationVit D or A intoxication

Pagets diseasePagets disease ImmobilizationImmobilization Thiazide diureticsThiazide diuretics Addisonian CrisisAddisonian Crisis Familial hypocalcuricFamilial hypocalcuric

hypocalcemiahypocalcemia

Neonatal severeNeonatal severehyperparathyroidism.hyperparathyroidism.


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HYPERCALCEMIAHYPERCALCEMIADIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Primary hyperparathyroidismPrimary hyperparathyroidism Hypercalcemia of malignancyHypercalcemia of malignancy

Familial hypocalcuricFamilial hypocalcurichypercalcemiahypercalcemia Granulomatous diseaseGranulomatous disease EndocrinopathiesEndocrinopathies

DrugsDrugs ImmobilizationImmobilization

S S S SSOCDISEASES ASSOCIATED WITH


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DISEASES ASSOCIATED WITHDISEASES ASSOCIATED WITHHYPERCALCEMIAHYPERCALCEMIA

Primary HyperparathyroidismPrimary Hyperparathyroidism 111 (54%)111 (54%)

Malignant DiseaseMalignant Disease 72 (35%)72 (35%)

UnknownUnknown 12 ( 6%)12 ( 6%)

Other CausesOther Causes 12 ( 6%)12 ( 6%)

TOTALTOTAL 207 (100%)207 (100%)


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ETIOLOGYETIOLOGYOF HYPERCALCEMIAOF HYPERCALCEMIA

Primary hyperparathyroidismPrimary hyperparathyroidism

Most common etiology inMost common etiology inoutpatientsoutpatients 1 in 500 to 1 in 10001 in 500 to 1 in 1000

Most common in 6thMost common in 6thdecadedecade Women > men, 3:2 ratioWomen > men, 3:2 ratio

Many patients found onMany patients found onroutineroutinescreening with minimalscreening with minimalsymptomssymptoms


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ETIOLOGY OFETIOLOGY OFHYPERCALCEMIAHYPERCALCEMIA

PrimaryPrimaryhyperparathyroidismhyperparathyroidism

80% due to80% due tosolitarysolitaryadenomaadenoma

4 gland4 glandhyperplasiahyperplasiaAssociation withAssociation with

MEN I and MEN IIMEN I and MEN II AA

5% are carcinoma5% are carcinoma


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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA

PrimaryPrimaryhyperparathyroidismhyperparathyroidism Labs -Labs - CaCa ++++,, POPO44

PTHPTH

urinary calciumurinary calciumexcretionexcretion


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Hypercalcemia of malignancyHypercalcemia of malignancy Humoral hypercalcemia of malignancyHumoral hypercalcemia of malignancy

Mediated by PTH-RPMediated by PTH-RP

Most often seen in solid tumorsMost often seen in solid tumors

Lung CA - squamous cell,Lung CA - squamous cell,adenocarcinoma, large celladenocarcinoma, large cell Breast CABreast CA Squamous cell CA of head and neck orSquamous cell CA of head and neck or

female repro tractfemale repro tract Renal cell CARenal cell CA

Not associated with bone metsNot associated with bone mets

Labs -Labs - CaCa ++++,, PTH,PTH, PTHrPPTHrP


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Hypercalcemia of malignancyHypercalcemia of malignancy Local osteolytic bone metastasisLocal osteolytic bone metastasis

Hematologic malignancies -Hematologic malignancies -multiple myelomamultiple myeloma

May be seen with breast CAMay be seen with breast CA

Local release of osteoclastLocal release of osteoclastactivating cytokinesactivating cytokines

Labs -Labs - CaCa ++++,, PTH andPTH andPTH-rPPTH-rP


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Familial hypocalcuric hypercalcemiaFamilial hypocalcuric hypercalcemia Autosomal dominant syndrome ofAutosomal dominant syndrome of

asymptomatic hypercalcemiaasymptomatic hypercalcemia

Must be ruled out before sendingMust be ruled out before sendingpatient to surgery for primary HPTHpatient to surgery for primary HPTH

Due to defect in calcium receptorDue to defect in calcium receptor Diagnose by measuringDiagnose by measuring

calcium/creatinine clearance (Cacalcium/creatinine clearance (CaUU/Cr/CrUUX CrX CrSS/Ca/CaSS))

HPTH > 0.03HPTH > 0.03

FHH < 0.01FHH < 0.01


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EndocrinopathiesEndocrinopathies HyperthyroidismHyperthyroidism

Direct effect to increase bone resorptionDirect effect to increase bone resorption

Adrenal insufficiency -Adrenal insufficiency - Volume contraction vs no glucocorticoidsVolume contraction vs no glucocorticoids

to oppose 1,25D action in gutto oppose 1,25D action in gut PheochromocytomaPheochromocytoma

Volume contractionVolume contraction Changes in PTH set pointChanges in PTH set point

Associated with MEN 2AAssociated with MEN 2A


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DrugsDrugs Vitamin D or A intoxicationVitamin D or A intoxication Thiazides - decrease urinary Ca excretionThiazides - decrease urinary Ca excretion

by potentiation of PTH action in kidneyby potentiation of PTH action in kidney Lithium - increased set point for inhibitionLithium - increased set point for inhibition

of PTH secretionof PTH secretion Milk-alkali syndromeMilk-alkali syndrome

Associated with use of large doses ofAssociated with use of large doses ofcalcium carbonatecalcium carbonate


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ImmobilizationImmobilization

Weight bearing is required for normalWeight bearing is required for normalbone remodellingbone remodelling

Prolonged bedrest results in increasedProlonged bedrest results in increasedosteoclastic resorption and decreasedosteoclastic resorption and decreasedbone formationbone formation

Usually not seen with normal renalUsually not seen with normal renalfunction. Renal insufficiency or volumefunction. Renal insufficiency or volume

depletion precedes development ofdepletion precedes development ofhypercalcemiahypercalcemia

Labs -Labs - CaCa ++++,, PTH, normal 25-PTH, normal 25-hydroxy and 1,25 dihydroxyvitamin Dhydroxy and 1,25 dihydroxyvitamin D

H l i


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HypercalcemiaHypercalcemia

intact PTHintact PTH

ElevatedElevated

Fractional excretion calciumFractional excretion calcium

SuppressedSuppressed

225(OH)vitamin D and 1,25(OH)25(OH)vitamin D and 1,25(OH)vitamin Dvitamin D

LowLow< 0.01< 0.01

Familial hypocalcuricFamilial hypocalcuric

hypercalcemiahypercalcemia

HighHigh> 0.03> 0.03

PrimaryPrimary

hyperparathyroidismhyperparathyroidism

GranulomatousGranulomatous

diseasediseaseor lymphomaor lymphoma

Normal to low 25-vit DNormal to low 25-vit D

HighHigh 1,25-vit D1,25-vit D

High 25-vit DHigh 25-vit D

and 1,25-vit Dand 1,25-vit D

Vitamin DVitamin Dintoxicationintoxication

Normal 25-vit DNormal 25-vit Dand 1,25-vit Dand 1,25-vit D

MalignancyMalignancyEndocrine causeEndocrine causeDrugsDrugs

ImmobilizationImmobilization

Known malignancKnown malignanc


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Localization StudiesLocalization Studies Noninvasive preoperative methodsNoninvasive preoperative methods

1.1. UltrasonographyUltrasonography2.2. Radioiodine or technetium thyroid scanRadioiodine or technetium thyroid scan3.3. Thallium-technetium scintigraphyThallium-technetium scintigraphy4.4. Technetium-99m sestamibi scintigraphyTechnetium-99m sestamibi scintigraphy5.5. Computed tomography scanComputed tomography scan6.6. Magnetic resonance imagingMagnetic resonance imaging

Invasive preoperative methodsInvasive preoperative methods1.1. Fine-needle aspirationFine-needle aspiration2.2. Selective arteriography or digital subtraction angiographySelective arteriography or digital subtraction angiography3.3. Selective venous sampling for parathyroid hormone assaySelective venous sampling for parathyroid hormone assay4.4. Arterial injection of selenium-ethionineArterial injection of selenium-ethionine

Intraoperative MethodsIntraoperative Methods1.1. Intraoperative ultrasonographyIntraoperative ultrasonography2.2.

Toluidine blue or methylene blueToluidine blue or methylene blue3.3. Urinary adenosine monophosphateUrinary adenosine monophosphate4.4. Quick parathyroid hormone intraoperativeQuick parathyroid hormone intraoperative

S ibi T h i 99


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Sestamibi-Technetium 99mSestamibi-Technetium 99m

ScintographyScintography Sestamibi taken up mitochondria of parathyroid cells greater thanSestamibi taken up mitochondria of parathyroid cells greater than

surrounding parenchyma.surrounding parenchyma. Inject 20 to 25 millicuries of technetium-99m sestamibi. ImagesInject 20 to 25 millicuries of technetium-99m sestamibi. Images

obtained at 10-15 minutes then 2-3 hours after the injection.obtained at 10-15 minutes then 2-3 hours after the injection. Late phase preferable for detecting parathyroid adenomas, asLate phase preferable for detecting parathyroid adenomas, as

thyroid nodules clear uptake faster than do parathyroid neoplasms.thyroid nodules clear uptake faster than do parathyroid neoplasms. Sensitivity (solitary adenoma) ~100%, Specificity ~90%.Sensitivity (solitary adenoma) ~100%, Specificity ~90%. False-positive:False-positive:

1.1. Solid thyroid nodules (adenomas)Solid thyroid nodules (adenomas)2.2. Hurthle cell carcinomaHurthle cell carcinoma3.3. Malignant thyroid lymph node metastasesMalignant thyroid lymph node metastases

4.4. No false-positive with cystic lesions of the thyroid glandNo false-positive with cystic lesions of the thyroid gland


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Continued.Continued.

Tc-99mTc-99mSestamibiSestamibi

suggestedsuggestedparathyroidparathyroidadenoma in Radenoma in R

inferior pole ofinferior pole ofthyroid gland.thyroid gland.


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Primary HPT - DiagnosisPrimary HPT - Diagnosis

Persistent Hypercalcaemia.Persistent Hypercalcaemia. Low serum phosphate.Low serum phosphate.

High normal or elevated PTHHigh normal or elevated PTHconcentration.concentration. 24h urinary Calcium excretion24h urinary Calcium excretion

Sestemebi scanSestemebi scan


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Indications for surgeryIndications for surgery

Nephrolithiasis, bone disease, andNephrolithiasis, bone disease, andneuromuscular symptoms respond well toneuromuscular symptoms respond well tosurgery.surgery.

Primary hyperparathyroidism due to adenoma isPrimary hyperparathyroidism due to adenoma iscured surgically by excision of the adenoma. Allcured surgically by excision of the adenoma. Allfour glands must be identified though!four glands must be identified though!

Primary hyperparathyriodism due to parathyroidPrimary hyperparathyriodism due to parathyroid

hyperplasia is treated with subtotalhyperplasia is treated with subtotalparathyroidectomy (3 1/2) or totalparathyroidectomy (3 1/2) or totalparathyroidectomy with autotranspantation intoparathyroidectomy with autotranspantation intothe arm.the arm.


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Surgical indications forSurgical indications forasymptomatic hyperparathyroidismasymptomatic hyperparathyroidism On initial evaluationOn initial evaluation

Markedly elevated CAMarkedly elevated CA Hx of life threateningHx of life threatening

hypercalcemia (??)hypercalcemia (??) Reduced Cr CL.Reduced Cr CL. NephrolithiasisNephrolithiasis Markedly elevatedMarkedly elevated

24hr U Ca24hr U Ca Substantially reducedSubstantially reduced

bone massbone mass

Following asymptomaticFollowing asymptomaticptpt Pt becomes symptomaticPt becomes symptomatic Ca 1-1.6 mg/100 ml aboveCa 1-1.6 mg/100 ml above

normalnormal NephrolithiasisNephrolithiasis Decline in bone massDecline in bone mass Neuro or psych problemsNeuro or psych problems

Pt desire to fix.Pt desire to fix.


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HYPERCALCEMIAHYPERCALCEMIATREATMENTTREATMENT

Acute treatment for any etiologyAcute treatment for any etiology Volume repletion with NS to increaseVolume repletion with NS to increase

Ca++ filtrationCa++ filtration Can add lasix (promotes calciumCan add lasix (promotes calcium

excretion) when volume repleteexcretion) when volume replete

More long term therapy is dependent onMore long term therapy is dependent onthe etiologythe etiology

TREATMENT OF HYPERCALCEMIATREATMENT OF HYPERCALCEMIA


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TREATMENT OF HYPERCALCEMIATREATMENT OF HYPERCALCEMIA

GENERAL PRINCIPLESGENERAL PRINCIPLES

Virtually all patients with severe andVirtually all patients with severe andsymptomatic hypercalcemia will be volumesymptomatic hypercalcemia will be volumedepleted. Volume replacement should be starteddepleted. Volume replacement should be started

first.first. Acute therapy of hypercalcemia is usuallyAcute therapy of hypercalcemia is usually

effective. Long term therapy is moreeffective. Long term therapy is moreproblematic.problematic.

TREATMENTS FOR HYPERCALCEMIATREATMENTS FOR HYPERCALCEMIA


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TREATMENTS FOR HYPERCALCEMIATREATMENTS FOR HYPERCALCEMIA

GENERAL SPECIFIC

Vol. Expansion (saline) I.V. Pamidronate

Diuresis (Lasix) I.V. Zoledronate

Mobilization Calcitonin

Restrict PO Calcium Gallium nitrate

Dialysis Plicamycin

Glucocorticoids

PhosphateIndomethacin

Antitumor Therapy


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Surgical ManagementSurgical Management

Clinical indicators for surgery*Clinical indicators for surgery*2.2. Serum calcium is >1.0 mg/dL above the upper limit ofSerum calcium is >1.0 mg/dL above the upper limit of

normal.normal.3.3. Creatinine clearance is reduced >30% for age in theCreatinine clearance is reduced >30% for age in the

absence of another cause.absence of another cause.4.4. Twenty-four hour urinary calcium is >400 mg/dL.Twenty-four hour urinary calcium is >400 mg/dL.5.5. Patients are younger than 50 years of age.Patients are younger than 50 years of age.6.6. Bone mineral density measurement at the lumbar spine,Bone mineral density measurement at the lumbar spine,

hip, or distal radius is reduced >2.5 standard deviationship, or distal radius is reduced >2.5 standard deviations

(by T score).(by T score).7.7. Patients request surgery, or patients are unsuitable forPatients request surgery, or patients are unsuitable forlong-term surveillance.long-term surveillance.

*Consensus conference held by the National Institutes of Health in

2002


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AdenomaAdenoma

2.2. Directed unilateral cervical exploration.Directed unilateral cervical exploration.

3.3.

Curative in >95% of patientsCurative in >95% of patients4.4. Preoperative localization withPreoperative localization withtechnetium-99m sestamibi + IOPTHtechnetium-99m sestamibi + IOPTH


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MEN 1MEN 1

1.1. Subtotal vs. total with autotransplantation.Subtotal vs. total with autotransplantation.

Men 2a-Men 2a-1.1. 100% cure rate with no recurrences whether100% cure rate with no recurrences whether

total parathyroidectomy, subtotaltotal parathyroidectomy, subtotalparathyroidectomy, or excision of enlargedparathyroidectomy, or excision of enlargedglands performed.glands performed.

2.2. R/O pheochromocytoma prior to OR tripR/O pheochromocytoma prior to OR trip(hypertensive crisis).(hypertensive crisis).


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Non-MEN familial hyperparathyroidismNon-MEN familial hyperparathyroidism(NMFH).(NMFH).

1.1. Subtotal or total (autotransplant) withSubtotal or total (autotransplant) with

bilateral cervical thymectomy.bilateral cervical thymectomy. Familial neonatal hyperparathyroidism.Familial neonatal hyperparathyroidism.

1.1. Total (autotransplant) + bilateralTotal (autotransplant) + bilateral

transcervical thymectomytranscervical thymectomy


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Renal failure-induced hyperparathyroidism.Renal failure-induced hyperparathyroidism.1.1. Subtotal vs. total parathyroidectomy (autotransplant) with orSubtotal vs. total parathyroidectomy (autotransplant) with or

without cryopreservation.without cryopreservation.

Parathyroid CarcinomaParathyroid Carcinoma1.1. en bloc resection of the tumor and areas of potential localen bloc resection of the tumor and areas of potential local

invasion and/or regional metastasis (ipsilateral central neckinvasion and/or regional metastasis (ipsilateral central neckcontents including the thyroid lobe and tracheoesophagealcontents including the thyroid lobe and tracheoesophagealsoft tissues, lymphatics, and resection of soft tissues withinsoft tissues, lymphatics, and resection of soft tissues withinthe superior anterior mediastinum)the superior anterior mediastinum)

2.2. RLN, esophageal wall, or strap muscles may require sacrificeRLN, esophageal wall, or strap muscles may require sacrificeif the tumor adheres to them.if the tumor adheres to them.

3.3. Not enough data to recommend for or against chemotherapyNot enough data to recommend for or against chemotherapyor RT.or RT.


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MIRPMIRP2.2. Preoperative administration of technetium 99m sestamibi beforePreoperative administration of technetium 99m sestamibi before

operation + intraoperative hand-held gamma probe.operation + intraoperative hand-held gamma probe.3.3. Advantages:Advantages:

Improved patient comfort postoperatively.Improved patient comfort postoperatively. Performance of ambulatory procedures.Performance of ambulatory procedures. Reduced cost.Reduced cost. Avoidance of general anesthetic.Avoidance of general anesthetic.

4.4. Disadvantages:Disadvantages:1.1. Potential for conversion to bilateral dissection in event of failedPotential for conversion to bilateral dissection in event of failed

exploration.exploration.2.2.

Patient anxiety when conversion needed (general anesthesia).Patient anxiety when conversion needed (general anesthesia).

F ili l B i H l iF ili l B i H l i


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Familial Benign HypercalcaemiaFamilial Benign Hypercalcaemia(FBH).(FBH).

Familial, AD. Family history important.Familial, AD. Family history important. Often come to light after failedOften come to light after failed

parathyroidectomyparathyroidectomy Benign. Asymptomatic.Benign. Asymptomatic. Low urinary calcium excretion.Low urinary calcium excretion.


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Primary HPT- treatmentPrimary HPT- treatment

Parathyroidectomy.Parathyroidectomy. Serum calcium should be normal withinSerum calcium should be normal within

24h.24h. Postoperative hypocalcaemia.Postoperative hypocalcaemia. Recurrent laryngeal nerve injury.Recurrent laryngeal nerve injury.


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TREATMENTTREATMENT

Hypercalcemia of malignancyHypercalcemia of malignancy IV PamidronateIV Pamidronate

Inhibits osteoclastic bone resorptionInhibits osteoclastic bone resorption

Takes 2-4 days to see full effectTakes 2-4 days to see full effect Must be given every 30-60 days toMust be given every 30-60 days to

prevent recurrence of hypercalcemiaprevent recurrence of hypercalcemia CalcitoninCalcitonin

Inhibits osteoclast actionInhibits osteoclast action

See an effect within 24 hrsSee an effect within 24 hrs

Effect wears off within 2-3 days due toEffect wears off within 2-3 days due totachyphalaxistachyphalaxis


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TREATMENTTREATMENT

Increased 1-hydroxylation of vitamin D due toIncreased 1-hydroxylation of vitamin D due togranulomatous diseasegranulomatous disease High dose steroids are effective inHigh dose steroids are effective in

sarcoidosissarcoidosis Questionable whether steroids are effective inQuestionable whether steroids are effective in

other granulomatous diseasesother granulomatous diseases

H l i f liHypercalcaemia of malignancy


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Hypercalcaemia of malignancyHypercalcaemia of malignancy

Carcinomas of breast, lung, head andCarcinomas of breast, lung, head andneck,renal.neck,renal.

Usually squamous carcinomas.Usually squamous carcinomas. PTHrP increasedPTHrP increased PTH normalPTH normal

Low serum albumin, high ESR, anemia.Low serum albumin, high ESR, anemia. Myeloma, local bone resorption.Myeloma, local bone resorption.


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SarcoidosisSarcoidosis

Small numbers of patients with sarcoidosisSmall numbers of patients with sarcoidosisdevelop hypercalcaemia.develop hypercalcaemia.

May develop after prolonged sunMay develop after prolonged sun

exposure.exposure. 1,25 diOH Vit D high, prodiced by alveolar1,25 diOH Vit D high, prodiced by alveolar

macrophages. PTH is normal.macrophages. PTH is normal. Corrected by SteroidsCorrected by Steroids


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ThyrotoxicosisThyrotoxicosis

Severe thyrotoxicosisSevere thyrotoxicosis Increased calcium release from boneIncreased calcium release from bone

(Thyroxine acts on bone)(Thyroxine acts on bone)

PTH is normalPTH is normal Takes 4-6 weeks to resolve withTakes 4-6 weeks to resolve with

antithyroid treatmentantithyroid treatment

Persistent hypercalcaemia usually meansPersistent hypercalcaemia usually meansconcomitant HPT.concomitant HPT.


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Band KeratopathyBand Keratopathy

HYPOCALCEMIAHYPOCALCEMIA


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HYPOCALCEMIA:HYPOCALCEMIA:ETIOLOGIESETIOLOGIES

HYPOPARATHYROID STATES:HYPOPARATHYROID STATES: AUTOIMMUNEAUTOIMMUNE CONGENITALCONGENITAL

DIGEORGE SYNDROMEDIGEORGE SYNDROME

POSTSURGICALPOSTSURGICAL SEVERE MAGNESIUM DEFICIENCYSEVERE MAGNESIUM DEFICIENCY NECK IRRADIATIONNECK IRRADIATION INFILTRATIVEINFILTRATIVE

HEMOCHROMATOSISHEMOCHROMATOSIS

SARCOIDOSISSARCOIDOSIS

WILSONS DISEASEWILSONS DISEASE HUNGRY BONE SYNDROMEHUNGRY BONE SYNDROME



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NONHYPOPARATHYROID STATESNONHYPOPARATHYROID STATES VITAMIN D DEFICIENCYVITAMIN D DEFICIENCY

LACK OF SUNLIGHT EXPOSURELACK OF SUNLIGHT EXPOSURE

DIETARY LACKDIETARY LACK

MALABSORPTIONMALABSORPTION UPPER GI SURGERYUPPER GI SURGERY

LIVER DISEASELIVER DISEASE

RENAL DISEASERENAL DISEASE

ANTICONVULSANTSANTICONVULSANTS

VITAMIN D DEPENDENT RICKETS (1VITAMIN D DEPENDENT RICKETS (1-HYDROXYLASE-HYDROXYLASEDEFICIENCY)DEFICIENCY)



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NONHYPOPARATHYROID STATESNONHYPOPARATHYROID STATES PARATHYROID HORMONE STATESPARATHYROID HORMONE STATES

PSEUDOHYPOPARATHYROIDISMPSEUDOHYPOPARATHYROIDISM

SEVERE MAGNESIUM DEFICIENCYSEVERE MAGNESIUM DEFICIENCY

VITAMIN D RESISTANCEVITAMIN D RESISTANCE DRUGSDRUGS

BISPHOSPHONATESBISPHOSPHONATES

CISPLATINUMCISPLATINUM

KETACONAZOLEKETACONAZOLE

PENTAMIDINEPENTAMIDINE

FOSCARNETFOSCARNET



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MISCELLANEOUSMISCELLANEOUS ACUTE PANCREATITISACUTE PANCREATITIS MASSIVE TUMOR LYSISMASSIVE TUMOR LYSIS

OSTEOBLASTIC METASTASESOSTEOBLASTIC METASTASES PHOSPHATE INFUSIONPHOSPHATE INFUSION MULTIPLE CITRATED BLOOD TRANSFUSIONSMULTIPLE CITRATED BLOOD TRANSFUSIONS ACUTE RHABDOMYOLYSISACUTE RHABDOMYOLYSIS

ACUTE SEVERE ILLNESSACUTE SEVERE ILLNESS

MANEFESTATIONS OFMANEFESTATIONS OF


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MANEFESTATIONS OFMANEFESTATIONS OFHYPOCALCEMIAHYPOCALCEMIA

NEUROLOGICNEUROLOGIC PERIPHERAL IRRITABILITY (TETANY)PERIPHERAL IRRITABILITY (TETANY)

+CHVOSTEKS AND TROUSSEAUS SIGNS+CHVOSTEKS AND TROUSSEAUS SIGNS CENTRAL IRRITABILITY (SEIZURES)CENTRAL IRRITABILITY (SEIZURES)

INTRACRANIAL CALCIFICATIONS (BASAL GANGLIA)INTRACRANIAL CALCIFICATIONS (BASAL GANGLIA) PAPILLEDEMAPAPILLEDEMA MENTAL CHANGESMENTAL CHANGES

CATARACTSCATARACTS ABNORMAL DENTITIONABNORMAL DENTITION

CARDIOVASCULARCARDIOVASCULAR PROLONGED Q-T INTERVALPROLONGED Q-T INTERVAL CHF, DIGITALIS RESISTANCECHF, DIGITALIS RESISTANCE



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HYPOCALCEMIA:HYPOCALCEMIA:SIGNSSIGNS

TREATMENT OF HYPOCALCEMIATREATMENT OF HYPOCALCEMIA


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ACUTE HYPOCALCEMIAACUTE HYPOCALCEMIA ASX PATIENT WITH MILD HYPOCALCEMIA (7.5-8.5 MG/DL): WATCH;ASX PATIENT WITH MILD HYPOCALCEMIA (7.5-8.5 MG/DL): WATCH;

MAY USE ORAL CALCIUM (500 TO 1000 MG PER DAY ELEMENTALMAY USE ORAL CALCIUM (500 TO 1000 MG PER DAY ELEMENTALCALCIUM)CALCIUM)

PATIENT WITH TETANY MUST TREAT WITH PARENTERAL CALCIUMPATIENT WITH TETANY MUST TREAT WITH PARENTERAL CALCIUM PATIENT WITH SERUM CALCIUM < 7.5 OR WITH SXS, TREAT WITHPATIENT WITH SERUM CALCIUM < 7.5 OR WITH SXS, TREAT WITH

PARENTERAL CALCIUMPARENTERAL CALCIUM USE CALCIUM GLUCONATE (90 MG/ 100 ML)USE CALCIUM GLUCONATE (90 MG/ 100 ML)

1 TO 2 AMPULES IN 50 TO 100 ML OF 5% DEXTROSE (180 MG1 TO 2 AMPULES IN 50 TO 100 ML OF 5% DEXTROSE (180 MGELEMENTAL CALCIUM) OVER 5 TO 10 MINELEMENTAL CALCIUM) OVER 5 TO 10 MIN

FOLLOW WITH 15 TO 20 MG/KG ELEMENTAL CALCIUM OVER 4FOLLOW WITH 15 TO 20 MG/KG ELEMENTAL CALCIUM OVER 4TO 6 HRTO 6 HR

WILL RAISE SERUM CALCIUM BY 2-3 MG/DLWILL RAISE SERUM CALCIUM BY 2-3 MG/DL

IF HYPOCALCEMIA IS LIKELY TO PERSIST, INITIATE ORALIF HYPOCALCEMIA IS LIKELY TO PERSIST, INITIATE ORALCALCIUM (1-2 GM PER DAY) WITH CALCITRIOL (O.5-1.0CALCIUM (1-2 GM PER DAY) WITH CALCITRIOL (O.5-1.0 g/day)g/day)

MONITOR SERUM MAGNESIUM AND REPLACE IF NECESSARYMONITOR SERUM MAGNESIUM AND REPLACE IF NECESSARY



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CHRONIC HYPOCALCEMIACHRONIC HYPOCALCEMIA START SUPPLEMENTAL ORAL CALCIUM (1-2START SUPPLEMENTAL ORAL CALCIUM (1-2

GM PER DAY) AND A VITAMIN DGM PER DAY) AND A VITAMIN DPREPARATION (ERGOCALCIFEROL 50,000PREPARATION (ERGOCALCIFEROL 50,000UNITS ONCE PER WEEK TO DAILY; ORUNITS ONCE PER WEEK TO DAILY; ORROCALTROL 0.5-1.0ROCALTROL 0.5-1.0 ICROGRAMS PER DAY)ICROGRAMS PER DAY)

MAINTAIN SERUM CALCIUM IN THE LOWMAINTAIN SERUM CALCIUM IN THE LOWNORMAL RANGE BECAUSE OF THE RISK OFNORMAL RANGE BECAUSE OF THE RISK OFHYPERCALCIURIA AND NEPHROLITHIASISHYPERCALCIURIA AND NEPHROLITHIASIS

C li ti f th idComplications of parathyroid surgery


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Complications of parathyroid surgery.Complications of parathyroid surgery.

HypocalcemiaHypocalcemia Persistent hypercalcemiaPersistent hypercalcemia Recurrent laryngeal nerve injuryRecurrent laryngeal nerve injury

paratyroid disease

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