Parathyroid part 2

Mendato A. Marcaban Jr
Special Situations

Normocalcemic Hyperparathyroidism
⚫ elevated PTH level with normal calcium (including ionized
calcium) levels
⚫ other secondary causes of elevated PTH should be ruled out,
namely:
⮚ vitamin D deficiency
⮚ Osteomalacia
⮚ hypercalciuria (renal leak)
⮚ renal insufficiency
⚫ normocalcemic HPT may represent a variant of “symptomatic”
PHPT and may not be an early form of “asymptomatic” disease
⚫ parathyroidectomy is more likely to be unsuccessful in these
patients
Parathyroid Carcinoma
⚫ 1% of PHPT cases
⚫ suspected preoperatively by the presence of:
⮚ severe symptoms
⮚ serum calcium levels >14 mg/dL
⮚ significantly elevated PTH levels (five times normal)
⮚ palpable parathyroid gland
⚫ 15% of patients have lymph node metastases
⚫ 33% have distant metastases at presentation
⚫ large, gray-white to gray-brown parathyroid tumor that is
adherent to or invasive into surrounding tissues like muscle,
thyroid, RLN, trachea, or esophagus
⚫ Accurate diagnosis necessitates histologic examination
⚫ major diagnostic criteria include:
⮚ vascular or capsular invasion
⮚ trabecular or fibrous stroma
⮚ frequent mitoses
Treatment
⚫neck exploration, with en bloc excision of the tumor and the ipsilateral
thyroid lobe, in addition to the removal of contiguous lymph nodes
(tracheoesophageal, paratracheal, and upper mediastinal)
⚫recurrent nerve is not sacrificed unless it is directly involved with
tumor
⚫Adherent soft tissue structures (strap muscles or other soft tissues)
should also be resected
⚫Modified radical neck dissection is recommended in the presence of
lateral lymph node metastases
⚫Prophylactic neck dissection is not advised
⚫ Reoperation is indicated for locally recurrent or metastatic
disease to control hypercalcemia.
⚫ Adjuvant radiation therapy should be considered in patients at
high risk of local recurrence such as those with close or positive
margins, invasion of surrounding structures, or tumor rupture
⚫ Radiation may also be used as primary therapy in unresectable
disease or for palliation of bone metastases
⚫ Chemotherapy is not very effective
⚫ Bisphosphonates have shown some effectiveness in treating
hypercalcemia associated with parathyroid carcinoma
Postoperative Care and Follow-Up
⚫ calcium level checks 2 weeks postoperatively, at 6 months, and
then annually
⚫ Recurrences are rare (<1%), except in patients with familial HPT
⚫ Recurrence rates of 15% at 2 years and 67% at 8 years have been
reported for MEN1 patients
Secondary Hyperparathyroidism

⚫ occurs in patients with chronic renal failure but also may occur in
those with hypocalcemia secondary to inadequate calcium or
vitamin D intake or malabsorption
⚫pathophysiology of HPT in chronic renal failure appears
to be related to:
⮚hyperphosphatemia (and resultant hypocalcemia)
⮚deficiency of 1,25-dihydroxy vitamin D due to loss of
renal tissue
⮚low calcium intake
⮚decreased calcium absorption
⮚abnormal parathyroid cell response to extracellular
calcium or vitamin D in vitro and in vivo
⚫ treated medically with:
⮚ low-phosphate diet
⮚ phosphate binders
⮚ adequate intake of calcium and 1, 25-dihydroxy vitamin D
⮚ high-calcium, low-aluminum dialysis bath
⮚ Calcimimetics to control parathyroid hyperplasia and osteitis
fibrosa cystica
⚫ parathyroidectomy if the glands are >1 cm (or >500 mm3) on
ultrasound
Tertiary Hyperparathyroidism

⚫ renal transplantation is an excellent method of treating

secondary HPT, but some patients develop autonomous
parathyroid gland function and tertiary HPT
⚫ Causes problems similar to PHPT, such as pathologic fractures,
bone pain and worsened bone disease, renal stones, peptic ulcer
disease, pancreatitis, and mental status changes
⚫ treated with cinacalcet
⚫ parathyroidectomy has been shown to lead to a more immediate
and dramatic reduction in hypercalcemic symptoms
⚫ subtotal or total parathyroidectomy with autotransplantation and
an upper thymectomy
Complications of Parathyroid Surgery

⚫ Occurs in 1%
⚫ transient and permanent vocal cord palsy and hypoparathyroidism
in patients who underwent four-gland exploration with biopsies,
subtotal resection with an inadequate remnant, or total
parathyroidectomy with a failure of autotransplanted tissue
⚫ Vocal cord paralysis and hypoparathyroidism are considered
permanent if they persist for >6 months
⚫Patients with symptomatic hypocalcemia or those with calcium
levels <8 mg/dL are treated with oral calcium supplementation
(up to 1–2 g every 4 hours)
⚫1,25-Dihydroxy vitamin D (calcitriol [Rocaltrol] 0.25–0.5 µg bid)
may also be required, particularly in patients with severe
hypercalcemia and elevated serum alkaline phosphatase levels
preoperatively and with osteitis fibrosa cystica
⚫Intravenous calcium supplementation rarely is needed, except
in cases of severe, symptomatic hypocalcemia.