GIANT PARATYROID ADENOMA VERSUS PARATHYROID CARCINOMA

Normalization of intraoperative parathyroid hormone does not predict normal postoperative parathyroid hormone levels

A 66-year-old Caucasian man with schizoaffective disorder was admitted to the psychiatric unit for a relapse of psychotic mania. The patient’s syndromal affective and psychotic symptoms had been in remission for the previous 11 years, duringwhich time the patient had been treatedwith lithium, 1200 mg/day, and olanzapine, 15 mg/day. He took no additional medications or supplements andwas otherwise healthy. Four months before admission, routine primary care screening revealed an elevated serum calcium level, at 11.0 mg/dL (reference range, 8.6–10.2 mg/dL). Records showed elevated calcium levels dating back 9 years. Three months before admission, the patient’s serum lithium levelwas 1.0mmol/L (reference range, 0.6–1.2 mmol/L) and his intact parathyroid hormone (iPTH) level was 92.2 pg/mL (reference range, 12–88 pg/mL). His primary care provider conferredwith an endocrinologist, who noted that lithium therapy is a well-documented cause of hypercalcemia and suggested discontinuing lithium. Lithiumwas discontinued and divalproex initiated at 1000 mg/day, 17 days before admission.At admission, the emergency department evaluation noted pressured speech, disorganized thought process, religious preoccupations, paranoia, five sleepless nights, elevated energy, labile mood, and uncharacteristically impulsive behaviors. Laboratory studies showed a serum calcium level of 10.7 mg/dL. Results of physical examination, comprehensive metabolic screening, CBC, and toxicology screeningwere otherwisenormal, aswas thepatient’s thyroidstimulating hormone level. An increase in the dosage of divalproex to 2000 mg/day, along with trials of olanzapine (20 mg/day), haloperidol (15 mg/day), and risperidone (4.5 mg/day), were ineffective in controlling the patient’s mania. The endocrinologydepartmentwas consulted once again to determine the risks and advisability of reinstituting lithium. The consultant recommended a further hypercalcemia workup. On hospital day 10, the patient’s calcium level normalized to 9.8 mg/dL, while his iPTH level was an inappropriately high-normal 76.7 pg/mL. His urinary calcium level was elevated at 362.5mg/24 hours (reference range, 100–300 mg). His 25-hydroxy vitamin D level was noted tobe lowat 21.0ng/mL(reference range, 30–100ng/mL). A technetium-99m sestamibi scan revealed increased uptake in one parathyroid gland, suggestive of adenoma. Bone mineral density testing by DXA (dual-energy X-ray absorptiometry) scan showed mild osteopenia in the left hip only (T-score51.4 SD). ECG results were unremarkable. Based on hypercalciuria and enhanced localized parathyroid uptake, the consultant diagnosed primary hyperparathyroidism. Because it was considered asymptomatic, surgical intervention was not deemed necessary. The consultant concluded that it was a reasonable risk to reinitiate lithium with follow-up monitoring in the endocrinology clinic. Lithium was restarted on hospital day 10 and titrated to the previously effective dosage. The patient’s manic psychosis remitted, and he was discharged on a regimen of lithium, 1200 mg/day, and risperidone, 3 mg/day. The patient remained in psychiatric remission at the 5week and 15-week follow-up appointments. Twelve weeks after discharge, his serum calcium and iPTH levels were again elevated at 10.7 mg/dL and 86.3 pg/mL, respectively, and his serum lithium level was 0.98 mmol/L.

INTRODUCTION/BACKGROUNDGiant parathyroid adenomas, defined as adenomas weighing >3.5 gm, are rare, comprising a small fraction of all parathyroid adenomas. We describe a patient who presented with a giant parathyroid adenoma and markedly elevated parathyroid hormone. CASEA 57-year-old male, with a family history of adrenal Cushing’s syndrome and hyperthyroidism, was incidentally diagnosed with primary hyperparathyroidism during admission for cerebral infarction, with hypercalcemia (3.2 mmol/L), elevated intact parathyroid hormone (iPTH) (140.2 pmol/L), and vitamin D deficiency (46 nmol/L). He was treated with saline diuresis, subcutaneous denosumab 60 mg, and subcutaneous calcitonin 200 U BD, but defaulted to further workup. Nine months later, he returned with altered sensorium, hypercalcemia (3.43 mmol/L) and elevated iPTH (448.9 pmol/L), the same treatment was given as in the previous admission. Ultrasound of the parathyroid showed an interior hypoechoic lesion measuring 2.0 x 2.6 x 3.2 cm. Tc-99m Sestamibi scan suggested a left inferior parathyroid lesion without an ectopic tissue. DXA scan showed osteoporotic changes in the distal third radius and femoral neck. KUB Ultrasound showed no renal calculi. One month later he was admitted for hypercalcemia and acute kidney injury, treated with saline diuresis and subcutaneous denosumab 120 mg, and eventually underwent left inferior parathyroidectomy with intraoperative iPTH monitoring. From his highest preoperative iPTH at 828 pmol/L, a reduction to 236.7 pmol/L was seen at 10-minutes post-incision. Intra-op findings showed a large left inferior parathyroid tumour, measuring 3.5 x 2.7 x 2.0 cm, weighing 14 gm. Histopathology was consistent with parathyroid adenoma. He was started on calcitriol and calcium carbonate post-operatively and did not develop hungry bone syndrome. CONCLUSIONIn giant parathyroid adenomas, a disproportionate rise in serum iPTH may result from factors like vitamin D deficiency, chronic iPTH elevation, or resistance to physiological effects of PTH. Distinguishing them from parathyroid carcinoma is challenging due to shared high iPTH and calcium levels, though studies showed that giant parathyroid adenomas may be asymptomatic. Histopathological examination is essential for diagnosis, warranting early surgical removal.

Cinacalcet hydrochloride (KRN1493) acts on the parathyroid calcium receptors to suppress parathyroid hormone (PTH) secretion, and is already in wide use in the United States and the European countries. In this study, we examined the efficacy and safety of cinacalcet in Japanese patients on maintenance haemodialysis. One hundred forty-four patients with serum intact PTH (iPTH) levels >or=300 pg/ml were enrolled and randomly allocated to two groups assigned to receive either cinacalcet or placebo for 14 weeks. Cinacalcet was started at the dose of 25 mg/day and titrated up to 100 mg/day to achieve the target iPTH level of <250 pg/ml. Cinacalcet significantly decreased the median iPTH level from 606.5 pg/ml to 241.0 pg/ml, despite the mean dialysis vintage being 2.4 times longer (14.3+/-7.1 years) and the proportion of patients receiving vitamin D sterols being higher, than in the phase 3 studies conducted in the US/EU. The target iPTH level was achieved in 51.4% of the patients in the cinacalcet group, in sharp contrast to only 2.8% in the placebo group. Furthermore, the percentage of patients with both the serum calcium and phosphorus levels within the target range in the K/DOQI guidelines increased from 4.2% to 26.4% by cinacalcet. These results suggest that lower dose levels of cinacalcet, as compared to those in US/EU studies, may be sufficient effectively suppress the serum iPTH levels and allow favourable management of the serum calcium and phosphorus levels in Japanese patients, having a longer average dialysis vintage.

A good therapeutic response to evocalcet for dropped head due to primary hyperparathyroidism: A case report

Background: Hypercalcemia due to cancer is an indicator of poor prognosis, and has been often found to be associated with the disseminated form of disease. Present study describes the serum and urinary calcium levels among the advanced cases of carcinoma breast with respect to stage of disease, presence of osseous metastases and also before and after treatment. It is a hospital based study done at Government Medical College, Jabalpur in Madhya Pradesh state of India.Methods: The present hospital-based and descriptive study was done at the Surgery Department of Government Medical College at Jabalpur in Madhya Pradesh, India. 50 patients with confirmed breast cancer diagnosis were enrolled in the study. Serum calcium was estimated by Clark and Collip’s method. Urinary calcium was estimated by Sulkowitch method. Serum and urinary calcium levels were compared with respect to stage of disease, presence of osseous metastases and also before and after treatment.Results: Out of 50 cases, raised level of serum calcium and positive urinary calcium was observed in all except 2 cases of stage II disease. Serum calcium levels were found to be higher in stage III and stage IV disease and the differences were found to be statistically significant. Serum calcium level was slightly more raised in cases with osseous metastasis (mean 14.4 mg%) in comparison with cases with non-osseous metastasis (mean 13.3 mg%) however, the difference was statistically not significant. Follow up data after treatment was available for 34 cases. After treatment, reduction in serum and urinary calcium levels was noted in all stages of disease and the decrease in serum calcium levels in stage III and stage IV disease was found to be statistically significant.Conclusions: Hypercalcemia was noticed in almost all cases of advanced carcinoma breast and the serum calcium levels were significantly higher in stage III and stage IV of the disease. There was a significant decrease in serum calcium levels after treatment of the disease which was predominantly surgical treatment alone or in combination with radiotherapy or chemotherapy.

Postoperative Hypocalcemia Following Parathyroidectomy for Giant Parathyroid Adenoma

Calcium and phosphate balance with quotidian hemodialysis

&lt;b&gt;Introduction&lt;/b&gt;: Primary hyperparathyroidism (PHPT) results from an excess secretion of parathyroid hormone (PTH), primarily due to parathyroid adenomas. These adenomas are more prevalent in women and, although rare, can develop into giant adenomas. One infrequent but notable complication of giant adenomas is parathyroid apoplexy. The aim of this manuscript is to describe the case of a Peruvian female patient diagnosed with PHPT secondary to a giant parathyroid adenoma, whose surgical treatment confirmed its apoplexy.&lt;br /&gt; &lt;b&gt;Case report&lt;/b&gt;: A 42-year-old Peruvian woman with hypertension and stage IV chronic kidney disease presented with a non-productive cough, dysphonia, and acute chest pain, revealing a mediastinal tumor on imaging. Physical examination showed no cervical tumors, and biochemical tests revealed elevated levels of total calcium and intact PTH, while serum phosphorus and calcitonin levels were normal. Imaging elucidated a parathyroid adenoma with mediastinal extension. Surgical intervention involved right parathyroidectomy, unveiling a 6 × 6 cm tumor with cystic and hemorrhagic degeneration, confirming the diagnosis of parathyroid apoplexy from a giant adenoma.&lt;br /&gt; &lt;b&gt;Conclusions&lt;/b&gt;: Giant parathyroid adenoma should be considered in patients presenting with a mediastinal mass and hypercalcemia. This condition can be complicated by parathyroid apoplexy in the context of PHPT. Timely imaging and surgical intervention are crucial for achieving optimal outcomes, with diagnosis confirmed through histopathology.

Background:Our study aims to explore the effect of total parathyroidectomy (PTX) with forearm autotransplantation (FAT) on the quality of life and recurrence of secondary hyperparathyroidism (SHPT) in chronic kidney disease patients.Methods:A total of 104 chronic kidney disease patients with SHPT were enrolled and divided into the PTX (n = 62) and PTX + FAT (n = 42) groups. The operation efficacy was evaluated by analyzing preoperative and postoperative values, including levels of intact parathyroid hormone (iPTH), serum phosphorus, serum calcium, alkaline phosphatase (ALP), calcium-phosphorus product, signs and symptoms, and MOS 36-item short-form health survey (SF-36) scores. Moreover, complications and recurrences were followed up for 12 months after the operation. Binary logistic regression was to present the risk factors for the recurrence of chronic kidney disease patients with SHPT.Results:Compared with the preoperative values, the PTX and PTX + FAT groups showed decrease postoperative levels of iPTH, serum phosphorus, serum calcium, calcium-phosphorus product, bone pain, and skin pruritus at all time periods. The PTX and PTX + FAT groups demonstrated decreased ALP, fracture or deformity, and coronary artery calcification at 1 month, decreased short stature at 3 months after the operation but increased SF-36 score after operation. Compared with the PTX group, the level of iPTH decreased and the levels of serum calcium, calcium-phosphorus product increased at 3, 6, and 12 months after the operation in the PTX + FAT group. The levels of ALP, fracture or deformity, short stature, and SF-36 decreased separately at 1 week and 6 and 12 months after the operation, along with the decrease of coronary artery calcification and the recurrence rate, respectively, at 6 and 12 months after the operation in the PTX + FAT group when compared with those in the PTX group. Logistic regression analysis evidenced that the preoperative iPTH level, SF-36 score, and operation type were the risk factors for the recurrence of chronic kidney disease with SHPT.Conclusion:Total PTX combined with FAT is more effective in improving the quality of life and reducing the recurrence of chronic kidney disease with SHPT than PTX alone.

Intermittent doxercalciferol (1α-Hydroxyvitamin D2) therapy for secondary hyperparathyroidism

Research on parathyroid ultrasound in kidney failure patients is highly relevant for understanding the relationship between parathyroid hormone levels and clinical conditions, optimizing therapeutic management for CKD patients. This study employs a quantitative observational descriptive design with cross-sectional approach to provide comprehensive overview of parathyroid ultrasound characteristics in CKD patients. Data were obtained from secondary medical records and parathyroid ultrasound examinations of CKD patients undergoing hemodialysis. This research shows that majority of chronic kidney disease (CKD) patients undergoing hemodialysis at Dr. Soetomo Regional Hospital in Surabaya have elevated serum iPTH and phosphate levels, while calcium levels are generally normal, though some patients experience hypocalcemia. Demographically, majority of patients are women (58%), aged 41–60 years, undergoing hemodialysis for 1–10 years. Parathyroid gland examination through ultrasound shows most patients have hypoechoic echogenicity, oval shape, well-defined borders, solid architecture, and size of 0.51–1 cm. More than half show no detectable vascularization, while some show perilesional blood flow patterns, serving as important indicators for detecting parathyroid hyperplasia. There is correlation between serum iPTH levels and morphological characteristics of parathyroid glands, including echogenicity, shape, size, and vascularization. At iPTH levels &lt;500 pg/dL, parathyroid appears isoechoic to hypoechoic, oval, solid, measuring approximately 0.51–1 cm, with minimal vascularization. At 500–1000 pg/dL, perilesional vascularization begins appearing. When iPTH levels &gt;1000 pg/dL, parathyroid enlarges (&gt;1 cm), becomes hypoechoic in texture, and vascularization increases significantly, indicating more prominent morphological and vascular changes associated with increasing iPTH levels.

SUN-272 Changes in whole PTH/intact PTH ratio in patients with chronic kidney disease

To investigate the diagnosis and management of primary hyperparathyroidism with urolithiasis. The clinical data of 12 patients who were diagnosed with primary hyperparathyroidism with urolithiasis from January 1998 to June 2004 were analyzed retrospectively. Four male and five female patients were demonstrated pathologically as parathyroid adenoma, with a mean age of 45.7 +/- 11.8 years (26 approximately 57) and a stone history of 8.3 +/- 6.4 years (0.5 approximately 22). Their serum calcium and PTH level were elevated obviously, while serum phosphate of 66% patients were lowered. The positive rate and accuracy of ultrasound, CT and (99m)TC-MIBI imaging were 67%, 100%, and 100% and 67%, 75%, 100% respectively. After resection of the parathyroid adenoma, the patients' serum calcium and PTH returned to normal. The other data of 3 cases without parathyroid adenoma. all males aged 45 approximately 54, were also investigated. Serum calcium level above 2.96 mmol/L and PTH 3.9 or more times as normal in patients with recurrent or bilateral urolithiasis should be suspected with primary hyperparathyroidism. (99m)TC-MIBI image functions best in preoperative localization of the abnormal gland. Parathyroidectomy is the curative approach for the disease. Stones should be followed up after operation and appropriate treatment should be employed when needed.

Background: A positive calcium balance may contribute to vascular calcification, while a negative balance increases iPTH. We explored the impact of different dialysate calcium concentrations on bone and mineral metabolism parameters according to pre-dialysis serum calcium levels. Results: Fifty-six hemodialysis patients were dialyzed with 3.0 or 2.5 mEq/l dialysate [calcium] in a crossover study of two weeks. Bone mineral metabolites were measured prior to and following the hemodialysis session. A 3.0 mEq/l dialysate [calcium] increased more post-dialysis total calcium and ionized calcium than 2.5 mEq/l dialysate [calcium]. The mildest dialysis-induced changes in calcium and PTH were observed in patients with pre-dialysis serum calcium <8.75 mg/dl dialyzed with 2.5 mEq/l dialysate [calcium] and in patients with pre-dialysis serum calcium >9.15 mg/dl dialyzed with 3.0 mEq/l calcium dialysate. Conclusion: In conclusion, the individualization of dialysate calcium concentration according to baseline pre-dialysis serum calcium may prevent major excursions in post-dialysis serum calcium and iPTH levels. Short Summary: High calcium dialysate may increase serum calcium in hemodialysis patients, while low dialysate calcium may increase PTH. Individualization of dialysate calcium according to predialysis serum calcium levels may prevent or decrease unwanted excursions of both serum calcium and PTH.