Vesalius Clinical Folios Discussion: Parathyroid Adenoma

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

Diagnosis

• Labs:

• Serum calcium (marked elevation suggestive carcinoma)

• Elevated 24 hour urinary calcium (rule out FHH)

• Intact PTH assay

• Radiology:

• 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

• Adenoma

• one or more enlarged gland

• one enlarged gland – resect

• two or more enlarged glands (resect with biopsy normal gland to rule out hyperplasia)

• Hyperplasia

• Non-familial

• radical subtotal (three and one-half-gland) parathyroidectomy

• pare remnant first to ensure viability

• 0 - 16% recurrence rate

• Familial

• 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

Complications

• 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

References
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.

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Related narrative: Parathyroid Adenoma
Diagnosis
•	Labs:
	•	Serum calcium (marked elevation suggestive carcinoma)
	•	Elevated 24 hour urinary calcium (rule out FHH)
	•	Intact PTH assay
•	Radiology:
	•	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
•	Adenoma
	•	one or more enlarged gland
	•	one enlarged gland – resect
	•	two or more enlarged glands (resect with biopsy normal gland to rule out hyperplasia)
•	Hyperplasia
	•	Non-familial
		•	radical subtotal (three and one-half-gland) parathyroidectomy
		•	pare remnant first to ensure viability
		•	0 - 16% recurrence rate
	•	Familial
		•	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

Complications
•	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

References 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.