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PubMedDate not supplied

[Surgical approach in the treatment of recurrent primary hyperparathyroidism].

Recurrent or persistent primary hyperparathyroidism (HPT) is a rare occurrence requiring generally a careful reoperation. From 1980 to 1992 a total of 192 patients underwent bilateral cervical exploration following a diagnosis of primary hyperparathyroidism. Persistent of recurrent HPT was found in 6 (3.04%) of our cases. In two patients a subtotal parathyroidectomy was performed (parathyroid hyperplasia) and hyperfunctioning parathyroid tissue was found at neck exploration. In one case an ectopic adenomatous fifth gland was found in mediastinum at reoperation. Three patients with recurrent HPT had a parathyroid carcinoma but in only two cases it was possible to identify and remove the pathologic tissue preoperatively localised in mediastinum by double-tracer scintigraphy and CT scan 6 and 15 months after first operation respectively. The third patient with parathyroid carcinoma was inoperable on account of multiple metastases both cervical and thoracic.

Follow-Up Studies↗
PubMed1998

Primary hyperparathyroidism and osteoporosis.

Primary hyperparathyroidism (PHPT) is considered a cause of secondary osteoporosis as a consequence of its known catabolic effect promoting osteoclast activity and bone resorption. However, recent in vitro and in vivo studies have shown that parathyroid hormone (PTH) may also have an anabolic effect on the mammalian skeleton. These two paradoxical effects of parathyroid hormone are discussed in the light of recent results of basic research, and of bone densitometric and histomorphometric data collected in patients affected by PHPT. Review of the literature leads to the conclusion that in PHPT skeletal damage involves prevalently cortical bone, while the mineral content of trabecular bone is preserved or even increased. On the basis of bone mineral density (BMD) measurements, osteoporosis prevalence in the early postmenopausal period seems to be significantly higher in women affected by PHPT than in the general population. As age progresses, osteoporosis prevalence seems to decrease in PHPT, while it increases exponentially with age in the general population. Similarly in PHPT, vertebral and appendicular fractures occur prevalently in the earlier decades of life with a higher frequency than in normal subjects, while with advancing age the fracture incidence becomes equal to that of the general population. When bone density is measured in lateral projection at lumbar level, BMD values in patients with mild asymptomatic PHPT are significantly higher than in controls. We conclude that PTH hypersecretion may represent a risk factor for osteoporosis and fractures in the young and in the early postmenopausal period, while it may have a protective effect on trabecular bone in elderly postmenopausal women.

Aged↗
PubMed2004

Biochemical effects from treatment with bisphosphonate and surgery in patients with primary hyperparathyroidism.

Patients with primary hyperparathyroidism (pHPT) are sometimes treated with bisphosphonates (BPs) as an alternative to surgery despite sparse documentation of the efficacy in this disorder. It is therefore of interest to study the biochemical effects from BPs in patients with pHPT. A series of 21 pHPT patients with serum calcium levels > 2.8 mmol/L were included. One month before surgery the patients underwent intravenous infusions of 30 to 40 mg pamidronate. Study parameters were total and ionized serum calcium, intact parathormone (PTH), alkaline phosphatase (ALP) and isoenzymes, creatinine, osteocalcin, 25-OH vitamin D(3), 1,25-OH(2 )vitamin D(3), urine calcium/creatinine, and osmolality. Registration of hypercalcemia-related symptoms were done by questionnaire. After pamidronate there was a temporary reduction in serum calcium with a nadir at 6 to 10 days. Normalization of serum calcium was achieved only by surgery. Intact PTH rose after pamidronate, with a maximum on day 6. Urinary calcium excretion was reduced after both pamidronate and surgery. ALP was reduced 30 days after pamidronate and also after surgery. Serum osteocalcin was not influenced by pamidronate. No statistically significant differences in symptoms were reported after treatment. In conclusion, there was a short, limited calcium-lowering effect from pamidronate in pHPT patients and a transient increase in PTH corresponding to the reduced calcium concentration. An obvious change in bone markers was found only after surgery. Treatment with BPs should not be considered an alternative to surgery, which is still the only method to cure patients with pHPT.

Adult↗
PubMed2005

Myocardial perfusion defects and the left ventricular ejection fraction disclosed by scintigraphy in patients with primary hyperparathyroidism.

Patients with primary hyperparathyroidism (PHPT) have increased risk of cardiovascular disease. For patients undergoing preoperative parathyroid imaging with 99mTc-sestamibi single photon emission computed tomography (SPECT), we combined cervical SPECT and gated cardiac SPECT to achieve information about the localization of parathyroid adenomas, myocardial perfusion, and the left ventricular ejection fraction (LVEF) at rest. A series of 22 patients with PHPT and no history of myocardial infarction or angina pectoris were recruited consecutively. At 60 minutes after injection of 700 MBq 99mTc-sestamibi, SPECT of the neck and gated myocardial perfusion SPECT were performed at the same time. All of the patients who underwent parathyroidectomy had the parathyroid adenoma localized as predicted from the SPECT. Five patients (23%) had myocardial perfusion defects extending more than 15% (range 15-25%), and they had higher plasma parathyroid hormone levels (p = 0.03), and lower LVEF (p = 0.007) than patients without perfusion defects. We suggest that patients with hyperparathyroidism and suspected cardiovascular disease can undergo 99mTc-sestamibi parathyroid SPECT simultaneously with gated myocardial perfusion SPECT to obtain information about the resting perfusion status and cardiac systolic function. The results from myocardial perfusion SPECT can lead to initiation of cardiovascular treatment and eventually perioperative precautions.

Adenoma↗
PubMed2002

Multiple endocrine neoplasia type 1 polymorphism D418D is associated with sporadic primary hyperparathyroidism.

BACKGROUND: Sporadic primary hyperparathyroidism (pHPT) occurs separately and in several hereditary disorders including multiple endocrine neoplasia type 1. Irradiation to the neck, female gender, and age are well-identified risk factors that predispose to pHPT. The multiple endocrine neoplasia type 1 gene is the most commonly deranged gene in parathyroid adenomas and contains several polymorphisms including D418D with a prevalence of roughly 50%. METHODS: We genotyped 162 pHPT patients and control participants to evaluate if the D418D polymorphism is related to development of pHPT. One hundred fourteen of the pHPT patients and control participants were recruited from a health screening and were subjected to measurement of bone mineral density (BMD) at the lumbar spine, femoral neck, and total body. RESULTS: The prevalence of each genotype (ie, MM, Mm, and mm) was for all pHPT patients: 62%, 29%, and 9%; and for all control participants: 32%, 43%, and 25% (P <.0004). For the screening-detected pHPT patients and control participants, the genotype distribution for MM, Mm, and mm was 60%, 30%, and 10%; and 31%, 44%, and 25%, respectively (P =.009). In the screening-recruited control participants, but not in pHPT patients, the MM genotype was also associated with higher total body BMD (P =.01) and BMD at the femoral neck (P =.02), whereas it failed to be significant for BMD at the lumbar spine (P =.08). CONCLUSIONS: We report that the MM genotype was overrepresented in pHPT patients compared with control participants, suggesting a novel marker for pHPT. Furthermore, the MM genotype was associated with higher BMD at the femoral neck and in the total body in the screening-recruited control participants.

Aged↗
PubMed1975

The effect of multiphasic biochemical screening on the diagnosis of primary hyperparathyroidism.

Experience of primary hyperparathyroidism (PHPT) at the Royal Brisbane Hospital was reviewed to determine the effect of multiphasic biochemical screening, introduced during 1970, on the rate of diagnosis of this disease. In the period 1959-1970, there were 28 proved cases and, in the period 1971-1974, 41 cases, an increase from 2.5 to 11.7 cases per annum. The main factor contributing to this increase was the inclusion of plasma calcium in the multiphasic screening programme, together with correction of the plasma calcium for the total protein concentration in the same blood sample.

Blood Proteins↗
PubMed1989

Possibilities and limits of the medical treatment for primary hyperparathyroidism.

Clinically obvious primary hyperparathyroidism is only curable by surgery. Medical treatment is debatable under other circumstances: mild chronic hypercalcemia, patients who refuse surgery, serious coexisting medical problems and recurrence or persistence of PHPT after surgical treatment. Prior to medical treatment, the usual common management of any mild hypercalcemia must be taken. The potential medical treatments are: (1) the inhibition of parathyroid hormone (PTH) secretion, and (2) the inhibition of the effects of PTH. The substances of these two main types are successively described. Nevertheless, no ideal medical treatment of PHPT is actually available.

Amifostine↗
PubMed2003

Ultrasound evaluation of carotid artery in primary hyperparathyroidism.

Patients with primary hyperparathyroidism (PHPT) have an increased cardiovascular morbidity and mortality. Elevated serum calcium and/or PTH may directly contribute to vascular tissue damage, but the role of classic factors for atherosclerosis has not fully been evaluated in this disease. The aim of our study was to dissect the potential effect of hypercalcemia and/or high PTH from that of major cardiovascular risk factors (i.e. diabetes mellitus, hyperlipidemia, hypertension, obesity, smoking habit) on the carotid artery structure of patients with PHPT. Twenty-six consecutive patients with PHPT [subdivided into two groups according to the absence (n = 10) or the presence (n = 16) of one or more risk factors] and 15 normocalcemic healthy subjects as controls were studied. At ultrasonography, a significant increase (P < 0.001) of carotid mean and maximum intima-media thickness, as well as a significant reduction of lumen diameter (P < 0.05) were found in the PHPT group with risk factors, compared with the other two groups. This suggests that hypercalcemia and/or PTH elevation per se are not determinant of carotid atherosclerosis in PHPT, and that increased cardiovascular mortality and morbility in this disease is attributable to the combined presence of classic cardiovascular risk factors.

Adult↗
PubMed2001

[Preoperative parathyroid scintigraphy in primary hyperparathyroidism].

BACKGROUND: The primary benefit of preoperative scintigraphy in patients with primary hyperparathyroidism not previously surgically explored seems to be the possibility of unilateral or limited access surgery in selected patients. MATERIAL AND METHODS: We studied the accuracy of scintigraphy using 99mTc sestamibi and dual phase imaging protocol combined with thyroid scintigraphy using 99mTc pertechnetate before conventional neck exploration and histologic verification in 78 consecutive patients. RESULTS: In 65 patients with solitary, focal uptake on scintigraphy, we found a solitary adenoma in 61 patients (94%), a solitary adenoma on the contralateral side in one patient, two adenomas on the indicated side in one patient, bilateral adenomas in one and hyperplasia in one patient. In 13 patients with a negative or equivocal scintigraphic result, eight had a solitary adenoma and five hyperplasia. INTERPRETATION: These result may support a limited unilateral surgical approach when scintigraphy shows a localized focal uptake and this is confirmed perioperatively. In experienced hands the risk of overlooking an adenoma will be small. However, it is mandatory to have an experienced parathyroid surgeon prepared to proceed with full neck exploration when this is necessary.

Adult↗
PubMed2002

Epidemiology of primary hyperparathyroidism in Europe.

Primary hyperparathyroidism (PHPT) is one of the most common endocrine diseases. Its clinical presentation has dramatically changed in the last 40 years, and now the disease typically affects elderly women and is characterized by mild hypercalcemia and few traditional classic (bone and kidney) manifestations. The change in clinical presentation was largely caused by development of automated serum calcium measurement in the early 1970s that made possible the introduction of serum calcium determination in the routine biochemical screening and the identification of a large number of "asymptomatic" patients. This led also to a 5-fold increase in the apparent incidence of PHPT for the identification of patients who were never diagnosed before (catch-up effect). From the most recent and accurate study, a 21/1000 PHPT prevalence was found in women aged 55-75 years, which is equivalent to 3/1000 prevalence in the general population. Epidemiological studies performed in Rochester, Minnesota, have shown an apparent decline in the annual incidence from 75 to approximately 20/100,000 in the last decade. Most of this apparent decline in the incidence of PHPT is explained by the decline of the "catch-up effect," although a number of factors that might result in changes in PHPT incidence have been identified. Vitamin D deficiency is particularly common in people living in Southern European countries, and this may contribute to underestimating the prevalence of PHPT, because total serum calcium may be normal in these patients. On the other hand vitamin D deficiency may be associated with more severe clinical expression of the disease, which may make clinically manifest otherwise mild asymptomatic cases. Irradiation of the neck and upper chest for benign diseases is a well-known risk factor for the development of PHPT, and a history of irradiation can be obtained in as many as 15-25% of PHPT patients. Because this therapeutic procedure is no longer used, the number of radiation-associated cases of PHPT is expected to progressively decline in the future. Restriction of healthcare financing may also contribute to the apparent decrease in the incidence of PHPT because calcium measurement is now performed only in patients who have a suspected abnormality in calcium homeostasis is. On the other hand, the screening for osteoporosis, which often includes serum calcium determination, is increasingly carried out in women around the sixth decade of life, when the incidence of PHPT is by far more frequent. In conclusion, the introduction of serum calcium screening in the early 1970s exerted an impressive effect on the epidemiology of PHPT, with an apparent incidence initially rising and then falling by the 1990s secondary to the diminution of the "catch-up effect." Other environmental, nutritional, or iatrogenic factors might influence the incidence of the disease, but the overall effect is unlikely to be relevant.

Adult↗
PubMedDate not supplied

Persistent elevated serum levels of intact parathyroid hormone after reoperation for primary hyperparathyroidism and after pamidronate therapy.

Primary hyperparathyroidism is a life-threatening rare disorder. It is seen as a result of neonatal primary hyperparathyroidism, familial hypocalciuric hypercalcemia, increased vitamin D levels and inactivation of calcium sensing receptor mutations. The clinical findings are hypotonia, bone demineralization, hypercalcemia and parathyroid hyperplasia. We present a six-month-old female patient, the first child of nonconsanguineous parents, who was referred for the investigation of failure to thrive, vomiting, constipation, fever, abdominal distention and hypotonia. Physical examination revealed weight under 3rd percentile, height 3rd-10th percentile, decreased subcutaneous fat, and distention of the abdomen. In neurological examination, hypotonia, motor-mental retardation, and active deep tendon reflexes were found. The biochemical values at the time of admission revealed primary hyperparathyroidism. Since hypercalcemia did not respond to calcitonin therapy and due to the mortality of hypercalcemia, parathyroidectomy was performed. Because hyperparathyroidism and hypercalcemia continued, angiography was done which revealed increased parathyroid hormone levels in the periphery of the innominate vein. Exploratory surgery followed, but hyperparathyroidism and hypercalcemia persisted after all of these procedures. Calcium-sensing receptor mutations and supernumerary gland were considered. Because hypercalcemia persisted, pamidronate therapy was initiated on a monthly basis.

Anti-Inflammatory Agents↗
PubMed1995

Increased bone mineral density after parathyroidectomy in primary hyperparathyroidism.

Skeletal involvement in primary hyperparathyroidism is characterized by preferential loss of cortical bone, whereas cancellous bone is relatively spared. Little data are available concerning changes in bone density, particularly at sites containing more cancellous bone, after successful parathyroidectomy. Most patients with primary hyperparathyroidism are asymptomatic, but approximately 50% meet one or more criteria for surgery. In a prospective study of 34 patients who met one or more such criteria, bone density rose at all skeletal sites (lumbar spine, femoral neck, and the radius) in the 4 yr after surgery. The lumbar spine, with most cancellous bone, showed a rapid (mean +/- SE, yr 1, 8.2 +/- 2.0%; P < 0.005) and sustained (yr 4, 12.8 +/- 2.8%; P < 0.001) rise. Post-menopausal patients were similar (by yr 4, 12.5 +/- 2.7%; P < 0.005). At the femoral neck, with intermediate cancellous and cortical composition, a similar increase was noted (12.7 +/- 3.8% by yr 4; P < 0.01). The distal radius, containing mostly cortical bone, rose modestly (4.0 +/- 1.5% by yr 3; P < 0.05), except in patients with lowest preoperative bone density, where the increase was marked (12.3 +/- 2.6% by yr 3; P < 0.05). In patients meeting surgical guidelines, parathyroidectomy is associated with improved bone mineral density.

Adult↗
PubMed1990

Unilateral neck exploration for primary hyperparathyroidism.

The operative approach to primary hyperparathyroidism due to a single adenoma remains controversial. We evaluated our experience with 75 patients presenting with primary hyperparathyroidism between January 1979 and September 1988. Prior to 1985 all patients underwent bilateral exploration. During this period, ultrasonographic localization in 6 patients proved highly accurate. Subsequently, routine preoperative ultrasonographic localization was used and patients were prospectively evaluated for the following: (1) incidence of unilateral exploration, (2) accuracy of ultrasonographic localization, (3) incidence of complications, and (4) operative time. Localization permitted unilateral exploration in 19 of 36 patients, although its accuracy depended on the interest of the radiologist involved. Institution A had an accuracy of 92%, while institution B had an accuracy of only 43%. There were fewer complications with unilateral exploration, and operative time was significantly less. Unilateral exploration based on preoperative ultrasonographic localization is recommended as the initial approach to primary hyperparathyroidism due to a single adenoma.

Adenoma↗
PubMed1988

Primary hyperparathyroidism in the elderly.

Primary hyperparathyroidism is a relatively common disease in elderly women. Many of its clinical presentations may be confused with normal aging. Among the elderly, renal dysfunction and skeletal disease, particularly osteoporosis, are the two aspects of the disease likely to cause the most morbidity. It is increasingly apparent, however, that a large group of patients with hyperparathyroidism are asymptomatic or only mildly symptomatic. When symptoms are present, or repeated serum calcium levels all exceed 11.0 mg/dL, surgery is considered the treatment of choice. Success of surgery and of postoperative recovery are not affected by the age of the patient, but are enhanced by the experience of the surgeon performing the parathyroidectomy. There are difficult management decisions to be made concerning the elderly asymptomatic patient with mild hypercalcemia. A conservative approach to therapy for these individuals would include maintenance of adequate hydration, and involvement in physical activity. Dietary restriction of calcium should be recommended only as long as there is no evidence that it is exacerbating negative calcium balance. Drugs likely to worsen hypercalcemia, such as thiazides, must be avoided, and blood chemistries should be monitored at regular intervals. Because the bone loss of hyperparathyroidism may develop insidiously, serial bone density measurements are probably reasonable in older women already at risk for osteoporosis. Accelerated bone loss is an indication for surgical intervention. A wide variety of medications have been proposed for the treatment of primary hyperparathyroidism, but none stands out as a particularly desirable therapeutic alternative. Future research in this area, particularly with the use of estrogens in postmenopausal women with hyperparathyroidism, may eventually lead to greater acceptance of this alternative to surgery.

Aged↗
PubMed2002

[Cystic parathyroid adenoma. A rare cause of primary hyperparathyroidism].

Two cases of primary hyperparathyroidism associated with parathyroid cysts were identified by an elevated plasma Ca++ level. The diagnosis was established preoperatively by the presence of high quantities of PTH in the cyst fluid in one of the patients. Cysts in the neck or superior mediastinum should raise suspicion of primary hyperparathyroidism.

Adenoma↗
PubMed1981

The surgical management of primary hyperparathyroidism: a personal series.

Primary hyperparathyroidism includes a spectrum of abnormalities relative to the size and histologic characteristics of the diseased glands. The lack of uniform agreement upon pathological interpretation and discrepancies between gross and histologic findings perpetuate the controversy regarding the mass of parathyroid tissue necessary to be resected. From 1960 to 1978, 193 primary hyperparathyroid patients (aged 20-80 years; mean: 55 years) were operated on by the senior author with a mean follow-up of 41.5 months. An approach evolved that included gross identification of all parathyroid tissue with frozen section confirmation and assessment of cellularity-the latter modifying the extent of parathyroid resection in 11 patients (11%) of 100 patients who had biopsies of at least four parathyroids. Overall persistence and recurrence rates of hypercalcemia were 6.2% (12 patients) and 1% (two patients), respectively, despite routine biopsy in 100 patients. No permanent hypocalcemia developed, but five patients (2.6%) were hypocalcemia one to 16 weeks postoperatively. No operative deaths occurred. Submission of additional parathyroid tissue by routine biopsy disclosed a higher prevalence of nodular hyperplasia than usually found, and the clinical significance of this finding is discussed. With findings based on gross and microscopic intraoperative study, the authors believe, the surgeon is better able to categorize pathologic variants of hyperparathyroidism and better equipped to deal with recurrent disease.

Adult↗
PubMed1983

Cimetidine does not correct circulating calcium and parathyroid hormone in primary hyperparathyroidism.

Thirteen patients with primary hyperparathyroidism were treated for 4-8 weeks with the H2-blocker cimetidine at a daily dose of 1 g. The drug had no effect on the serum concentrations of calcium or parathyroid hormone, nor did any of the patients improve clinically during the period of treatment. The recently reported efficacy of cimetidine in primary hyperparathyroidism is strongly questioned by the present results.

Adult↗
PubMed2006

Primary hyperparathyroidism and the cardiovascular system.

The role of primary hyperparathyroidism (PHPT) in heart disease is still somewhat uncertain in many respects. Patients with PHPT seem to have an increase in mortality and this seems mainly due to an overrepresentation of cardiovascular death. PHPT is reported to be associated with hypertension, disturbances in the renin-angiotensin-aldosterone system, cardiac arrhythmias as well as structural and functional alterations in the vascular wall. There is an increased prevalence of cardiac structural abnormalities such as LVH and functional properties of the heart may be affected by the hyperparathyroid condition as well. We report the case of a 65-year-old woman with no cardiac risk factors apart from her age and type 2 diabetes who presented in cardiogenic shock. Extensive evaluation for the aetiology of the cardiomyopathy revealed solely a diagnosis of primary hyperparathyroidism. Cardiac manifestations of primary hyperparathyroidism have been reported before but to our knowledge this is the first description of severe left ventricular function secondary to PHPT. We believe that this atypical presentation of primary hyperparathyroidism causing left ventricular cardiomyopathy warrants further attention, and that a diagnosis of primary hyperparathyroidism should always be considered in patients with systolic as well as diastolic left ventricular dysfunction, and no other obvious cause.

Female↗