c l i n i c a l f o l i o s : d i s c u s s i o n

Parathyroid Adenoma



Related narrative: Parathyroid Adenoma

  Serum calcium (marked elevation suggestive carcinoma)
  Elevated 24 hour urinary calcium (rule out FHH)
  Intact PTH assay
  Xrays – subperiosteal bone reabsorption, osteitis fibrosa cystica (bone reabsorption, cysts, brown tumors) – found < 10% patients
  Localization studies (clearly indicated for recurrent or persistent disease)
  99m Tc sestamibi – sensitivity 90%, also effective at localization (89%) and differentiation between adenoma and hyperplasia (83%)
  Ultrasound – sensitivity unoperated patients of 70-80%, 40% after operation
  CT/MRI – reoperative accuracy of 50-80%
  Venous sampling
Non-Operative Therapy
Hypercalcemic crisis – muscular weakness, nausea and vomiting, fatigue, drowsiness, and confusion, serum Ca > 14
  treatment with NS followed by furosamide diuresis, calcitonin, steroids, mithramycin, orthophosphate
Management with medications (as above) only for those with extensive surgical risk
Operative Approach
Parathyroidectomy in both symptomatic and asymptomatic patients results in normalization of serum values and increased bone density
  one or more enlarged gland
  one enlarged gland – resect
  two or more enlarged glands (resect with biopsy normal gland to rule out hyperplasia)
    radical subtotal (three and one-half-gland) parathyroidectomy
    pare remnant first to ensure viability
    0 - 16% recurrence rate
    total parathyroidectomy and heterotopic autotransplantation (non-dominant forearm) with parathyroid cyropreservation
  No enlarged parathyroid gland – exploration of the upper mediastinum, retroesophageal area, carotid sheaths, and thyroid gland. If negative then close and proceed to localization studies (i.e., sestamibi) with directed re-exploration and possible median sternotomy
  Minimally invasive radioguided parathyroidectomy
    Preoperative technetium 99m-labeled sestamibi scanning
    Gamma counter directed minimal incision and dissection
    ex vivo radiation measurements resected parathyroid tissue
    intraoperative PTH assay
Postoperative hypoparathyroidism
  serum calcium level reaches its lowest level in 48 to 72 hours and returns to normal 2 to 3 days
  treat if Ca < 7 or patient symptomatic (numbness and tingling in the circumoral area, the fingers, and the toes, anxiety, depression, tetany positive Chvostek's or Trousseau's sign)
Recurrent laryngeal nerve injury (1-2% rate)
Postoperative hematoma
  bedside exploration if symptomatic

Johnston LB – J Clin Endocrinol Metab – 1996 Jan; 81(1): 346-52

Silverberg SJ – N Engl J Med – 1999 Oct 21; 341(17): 1249-55

Norman J, Chheda H – Surgery – 122:998-1004, 1997

Textbook of surgery: the biological basis of modern surgical practice. – 15th ed. / [edited by] David C. Sabiston, Jr.; editor for basic surgical science, H. Kim Lyerly

This page was last modified on 3-May-2000.