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8/14/2019 Paratyroid Disease
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AnatomyAnatomy
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AnatomyAnatomy
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Anatomy / EmbryologyAnatomy / Embryology
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Parathyroid Anatomy and Histopathology:Parathyroid Anatomy and Histopathology:The Normal Parathyroid GlandThe Normal Parathyroid Gland
Supernumerary fifth parathyroid found betweenSupernumerary fifth parathyroid found between0.7%-5.8% patients0.7%-5.8% patients
55thth glands found in the mediastinum (thymus orglands found in the mediastinum (thymus orrelated to the aortic arch), thyrothymic tractrelated to the aortic arch), thyrothymic tract
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PATHOLOGYPATHOLOGY
HYPERPARATHYROIDISMHYPERPARATHYROIDISM
1 : 1,000 prevalence1 : 1,000 prevalence
F : M 2 : 1F : M 2 : 1
Usually mild / asymptomaticUsually mild / asymptomatic
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Histopathology of the Parathyroid GlandsHistopathology of the Parathyroid Glands
Parathyroid gland composed of chief cells, oxyphilic cellsParathyroid gland composed of chief cells, oxyphilic cellsand intermediate cellsand intermediate cells
Solitary parathyroid adenoma ~80%-85% of patients withSolitary parathyroid adenoma ~80%-85% of patients withprimary hyperparathyroidismprimary hyperparathyroidism
Variations in parathyroid adenoma includes otherVariations in parathyroid adenoma includes othersubtypes (oncocytic adenoma, lipoadenoma, large clearsubtypes (oncocytic adenoma, lipoadenoma, large clearcell adenoma, water-clear cell adenoma, and atypicalcell adenoma, water-clear cell adenoma, and atypicaladenoma).adenoma).
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Ob P1- parathyroid glands and the physiology of calcium hemostasis.Ob P1- parathyroid glands and the physiology of calcium hemostasis.
Synthesize and secret parathyroid hormone,Synthesize and secret parathyroid hormone,which along with vitamin D maintains calciumwhich along with vitamin D maintains calciumhemostasis.hemostasis.
Calcium PTH
Bone resorption,urine phosphorus
Renal resorption
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Ca++Ca++
Ca++Ca++
PTHPTH
1,25D1,25D
1,25D1,25D
--
--
ParathyroidsParathyroids
KidneyKidneyBoneBone
GI tractGI tract
Careabsorb
Careab
sorb
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Calcium MetabolismCalcium Metabolism
Intestine Bone kidney (2.1-2.6 mmol/l)Intestine Bone kidney (2.1-2.6 mmol/l) 97% of reservoir in bone, chronic regulation.97% of reservoir in bone, chronic regulation. Kidney involved in minute to minute flux.FiltersKidney involved in minute to minute flux.Filters
8000mg daily.8000mg daily. Net intestinal absorption is 200mg daily..Net intestinal absorption is 200mg daily.. If long term calcium losses exceed net calciumIf long term calcium losses exceed net calcium
absorption the deficit is resorbed from boneabsorption the deficit is resorbed from boneleading to demineralisation.leading to demineralisation.
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Calcium Metabolism - PTHCalcium Metabolism - PTH
Parathyroid Hormone (PTH), 84 AAParathyroid Hormone (PTH), 84 AAstructure. Secreted from parathyroid glandstructure. Secreted from parathyroid glandin response to hypocalcemia.in response to hypocalcemia.
Amino terminal (1-34 AA) contains theAmino terminal (1-34 AA) contains thebiological activity.biological activity.
PTH acts on receptors in target tissuesPTH acts on receptors in target tissues
leading to stimulation of adenylayeleading to stimulation of adenylayecyclase activity.cyclase activity.
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Calcium Metabolism- Vitamin DCalcium Metabolism- Vitamin D
Vitamin D formed in skin(D3 or cholecalciferol) by uvVitamin D formed in skin(D3 or cholecalciferol) by uv
light. Major source of vitamin D (90%). Also present inlight. Major source of vitamin D (90%). Also present indiet. This is the inert formdiet. This is the inert form Hydroxylated in the liver to 25-OH-VitD.Hydroxylated in the liver to 25-OH-VitD. Renal hydroxylation to 1,25 dihydroxy vitamin D (veryRenal hydroxylation to 1,25 dihydroxy vitamin D (very
active metabolite). Renal also produces 24,25 dihydroxyactive metabolite). Renal also produces 24,25 dihydroxyvit D. (inactive)vit D. (inactive) Calcium deficiency leads to 1,25 Dit D productionCalcium deficiency leads to 1,25 Dit D production 1,25 vit D acts on small intestine to increase calcium1,25 vit D acts on small intestine to increase calcium
absorption.absorption. Also acts on bone to cause resorption.Also acts on bone to cause resorption.
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Effects of PTHEffects of PTH
Increases calcium reabsorption by theIncreases calcium reabsorption by thekidney.kidney.
Decreases phosphate reabsorption by theDecreases phosphate reabsorption by thekidney.kidney.
Increases osteoclastic bone resorption.Increases osteoclastic bone resorption.
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Three forms of calcium in serumThree forms of calcium in serum
Ionised (physiological form).Ionised (physiological form). Protein-bound (50%), mainly to albuminProtein-bound (50%), mainly to albumin
Complexed to citrate and phosphate(1-Complexed to citrate and phosphate(1-2%).2%).
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Causes of HypercalcaemiaCauses of Hypercalcaemia
COMMON (97%) ofCOMMON (97%) of
all casesall cases
PrimaryPrimary
HyperparathyroidismHyperparathyroidism MalignancyMalignancy
LESS COMMONLESS COMMON
Familial benignFamilial benignhypercalcaemiahypercalcaemia
(FBH)(FBH) SarcoidosisSarcoidosis ThyrotoxicosisThyrotoxicosis
Vitamin D poisoningVitamin D poisoning Acute renal failureAcute renal failure
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Causes of Hypercalcemia-RARECauses of Hypercalcemia-RARE
ImmobilisationImmobilisation VIPomasVIPomas TuberculosisTuberculosis Milk-alkali syndromeMilk-alkali syndrome Addisons DiseaseAddisons Disease LithiumLithium Thiazide diureticsThiazide diuretics Parenteral feedingParenteral feeding
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List the causes, symptoms, and signs of hypercalcemia.List the causes, symptoms, and signs of hypercalcemia.
StonesStones NephrolithiasisNephrolithiasis
BonesBones Painful resorption of bonePainful resorption of bone Moans and Psychatric overtonesMoans and Psychatric overtones
Fatigue, depression, confusionFatigue, depression, confusion Abdominal groansAbdominal groans
Peptic ulcer and pancreatitisPeptic ulcer and pancreatitis
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SymptomsSymptoms
Tiredness and lethargyTiredness and lethargy Proximal muscle weaknessProximal muscle weakness
Polyuria, nocturia and thirstPolyuria, nocturia and thirst Nausea Vomiting and constipationNausea Vomiting and constipation Depression, psychosis and impairedDepression, psychosis and impaired
consciousness.consciousness.
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SIGNS AND SYMPTOMSSIGNS AND SYMPTOMSOF HYPERCALCEMIAOF HYPERCALCEMIA
CNSCNS
Lethargy, drowsinessLethargy, drowsiness
DepressionDepression
PsychosisPsychosis
Stupor, comaStupor, coma
NeuromuscularNeuromuscular
WeaknessWeakness
Proximal muscle weaknessProximal muscle weakness
HypotoniaHypotonia
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SIGNS ANDSIGNS ANDSYMPTOMSSYMPTOMSOFOF
HYPERCALCEMIAHYPERCALCEMIA
CardiovascularCardiovascular HTNHTN
ArrhythmiaArrhythmia Short QTShort QT
RenalRenal
Polyuria and polydipsiaPolyuria and polydipsiavolume depletionvolume depletion
Renal stonesRenal stones
NephrocalcinosisNephrocalcinosis
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SIGNS AND SYMPTOMS OFSIGNS AND SYMPTOMS OFHYPERCALCEMIAHYPERCALCEMIA
MusculoskeletalMusculoskeletal
Myalgias and arthralgiasMyalgias and arthralgias Metastatic calcificationsMetastatic calcifications
Ca-PO4 product > 70Ca-PO4 product > 70
BoneBone Osteitis fibrosis cysticaOsteitis fibrosis cystica OsteoporosisOsteoporosis FractureFracture
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SIGNS AND SYMPTOMSSIGNS AND SYMPTOMSOF HYPERCALCEMIAOF HYPERCALCEMIA
GI tractGI tractConstipationConstipation
Anorexia, N/VAnorexia, N/V
Dyspepsia, PUDDyspepsia, PUD
PancreatitisPancreatitis
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Know the difference between 1, 2, 4Know the difference between 1, 2, 4hyperparathyroidism.hyperparathyroidism.
PrimaryPrimary HyperparathyroidismHyperparathyroidismPTH calcium (normal renal function)PTH calcium (normal renal function)83% parathyroid adenoma, 15% parathyroid83% parathyroid adenoma, 15% parathyroid
hyperplasia, carcinoma ishyperplasia, carcinoma is rarerare 1-2%1-2% SecondarySecondary HyperparathyroidismHyperparathyroidism
poor renal functionpoor renal function calcium, POcalcium, PO44 PTHPTH
normal Canormal Ca TertiaryTertiary HyperparathyroidismHyperparathyroidism
Hyperplastic parathyroids from chronicHyperplastic parathyroids from chronicstimulation continue post renal transplantstimulation continue post renal transplant
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Primary HPTPrimary HPT
500 cases/million500 cases/million More common in femalesMore common in females
Incidence increases with ageIncidence increases with age Autonomous production of PTHAutonomous production of PTH Benign AdenomaBenign Adenoma
Asymptomatic pick-up.Asymptomatic pick-up.
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Hyperparathyroidism in other syndromesHyperparathyroidism in other syndromes(RARE)(RARE)
MEN Type 1 (Parathyroid adenoma, PituitaryMEN Type 1 (Parathyroid adenoma, Pituitaryadenoma, and pancreatic islet cell tumours).adenoma, and pancreatic islet cell tumours).
MEN Type 2 (Parathyroid adenoma, medullaryMEN Type 2 (Parathyroid adenoma, medullary
thyroid carcinoma and phaeochromocytoma)thyroid carcinoma and phaeochromocytoma)
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Discuss ddx of a paitent with hypercalcemia.Discuss ddx of a paitent with hypercalcemia.
HyperparathyroidismHyperparathyroidism MalignancyMalignancy
HematologicHematologic PTHrP producerPTHrP producer
HyperthyroidsmHyperthyroidsm Multiple myelomaMultiple myeloma
SarcoidosisSarcoidosis Milk-alkili syndromeMilk-alkili syndrome Vit D or A intoxicationVit D or A intoxication
Pagets diseasePagets disease ImmobilizationImmobilization Thiazide diureticsThiazide diuretics Addisonian CrisisAddisonian Crisis Familial hypocalcuricFamilial hypocalcuric
hypocalcemiahypocalcemia
Neonatal severeNeonatal severehyperparathyroidism.hyperparathyroidism.
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HYPERCALCEMIAHYPERCALCEMIADIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Primary hyperparathyroidismPrimary hyperparathyroidism Hypercalcemia of malignancyHypercalcemia of malignancy
Familial hypocalcuricFamilial hypocalcurichypercalcemiahypercalcemia Granulomatous diseaseGranulomatous disease EndocrinopathiesEndocrinopathies
DrugsDrugs ImmobilizationImmobilization
S S S SSOCDISEASES ASSOCIATED WITH
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DISEASES ASSOCIATED WITHDISEASES ASSOCIATED WITHHYPERCALCEMIAHYPERCALCEMIA
Primary HyperparathyroidismPrimary Hyperparathyroidism 111 (54%)111 (54%)
Malignant DiseaseMalignant Disease 72 (35%)72 (35%)
UnknownUnknown 12 ( 6%)12 ( 6%)
Other CausesOther Causes 12 ( 6%)12 ( 6%)
TOTALTOTAL 207 (100%)207 (100%)
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ETIOLOGYETIOLOGYOF HYPERCALCEMIAOF HYPERCALCEMIA
Primary hyperparathyroidismPrimary hyperparathyroidism
Most common etiology inMost common etiology inoutpatientsoutpatients 1 in 500 to 1 in 10001 in 500 to 1 in 1000
Most common in 6thMost common in 6thdecadedecade Women > men, 3:2 ratioWomen > men, 3:2 ratio
Many patients found onMany patients found onroutineroutinescreening with minimalscreening with minimalsymptomssymptoms
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ETIOLOGY OFETIOLOGY OFHYPERCALCEMIAHYPERCALCEMIA
PrimaryPrimaryhyperparathyroidismhyperparathyroidism
80% due to80% due tosolitarysolitaryadenomaadenoma
4 gland4 glandhyperplasiahyperplasiaAssociation withAssociation with
MEN I and MEN IIMEN I and MEN II AA
5% are carcinoma5% are carcinoma
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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA
PrimaryPrimaryhyperparathyroidismhyperparathyroidism Labs -Labs - CaCa ++++,, POPO44
PTHPTH
urinary calciumurinary calciumexcretionexcretion
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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA
Hypercalcemia of malignancyHypercalcemia of malignancy Humoral hypercalcemia of malignancyHumoral hypercalcemia of malignancy
Mediated by PTH-RPMediated by PTH-RP
Most often seen in solid tumorsMost often seen in solid tumors
Lung CA - squamous cell,Lung CA - squamous cell,adenocarcinoma, large celladenocarcinoma, large cell Breast CABreast CA Squamous cell CA of head and neck orSquamous cell CA of head and neck or
female repro tractfemale repro tract Renal cell CARenal cell CA
Not associated with bone metsNot associated with bone mets
Labs -Labs - CaCa ++++,, PTH,PTH, PTHrPPTHrP
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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA
Hypercalcemia of malignancyHypercalcemia of malignancy Local osteolytic bone metastasisLocal osteolytic bone metastasis
Hematologic malignancies -Hematologic malignancies -multiple myelomamultiple myeloma
May be seen with breast CAMay be seen with breast CA
Local release of osteoclastLocal release of osteoclastactivating cytokinesactivating cytokines
Labs -Labs - CaCa ++++,, PTH andPTH andPTH-rPPTH-rP
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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA
Familial hypocalcuric hypercalcemiaFamilial hypocalcuric hypercalcemia Autosomal dominant syndrome ofAutosomal dominant syndrome of
asymptomatic hypercalcemiaasymptomatic hypercalcemia
Must be ruled out before sendingMust be ruled out before sendingpatient to surgery for primary HPTHpatient to surgery for primary HPTH
Due to defect in calcium receptorDue to defect in calcium receptor Diagnose by measuringDiagnose by measuring
calcium/creatinine clearance (Cacalcium/creatinine clearance (CaUU/Cr/CrUUX CrX CrSS/Ca/CaSS))
HPTH > 0.03HPTH > 0.03
FHH < 0.01FHH < 0.01
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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA
EndocrinopathiesEndocrinopathies HyperthyroidismHyperthyroidism
Direct effect to increase bone resorptionDirect effect to increase bone resorption
Adrenal insufficiency -Adrenal insufficiency - Volume contraction vs no glucocorticoidsVolume contraction vs no glucocorticoids
to oppose 1,25D action in gutto oppose 1,25D action in gut PheochromocytomaPheochromocytoma
Volume contractionVolume contraction Changes in PTH set pointChanges in PTH set point
Associated with MEN 2AAssociated with MEN 2A
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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA
DrugsDrugs Vitamin D or A intoxicationVitamin D or A intoxication Thiazides - decrease urinary Ca excretionThiazides - decrease urinary Ca excretion
by potentiation of PTH action in kidneyby potentiation of PTH action in kidney Lithium - increased set point for inhibitionLithium - increased set point for inhibition
of PTH secretionof PTH secretion Milk-alkali syndromeMilk-alkali syndrome
Associated with use of large doses ofAssociated with use of large doses ofcalcium carbonatecalcium carbonate
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ETIOLOGY OF HYPERCALCEMIAETIOLOGY OF HYPERCALCEMIA
ImmobilizationImmobilization
Weight bearing is required for normalWeight bearing is required for normalbone remodellingbone remodelling
Prolonged bedrest results in increasedProlonged bedrest results in increasedosteoclastic resorption and decreasedosteoclastic resorption and decreasedbone formationbone formation
Usually not seen with normal renalUsually not seen with normal renalfunction. Renal insufficiency or volumefunction. Renal insufficiency or volume
depletion precedes development ofdepletion precedes development ofhypercalcemiahypercalcemia
Labs -Labs - CaCa ++++,, PTH, normal 25-PTH, normal 25-hydroxy and 1,25 dihydroxyvitamin Dhydroxy and 1,25 dihydroxyvitamin D
H l i
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HypercalcemiaHypercalcemia
intact PTHintact PTH
ElevatedElevated
Fractional excretion calciumFractional excretion calcium
SuppressedSuppressed
225(OH)vitamin D and 1,25(OH)25(OH)vitamin D and 1,25(OH)vitamin Dvitamin D
LowLow< 0.01< 0.01
Familial hypocalcuricFamilial hypocalcuric
hypercalcemiahypercalcemia
HighHigh> 0.03> 0.03
PrimaryPrimary
hyperparathyroidismhyperparathyroidism
GranulomatousGranulomatous
diseasediseaseor lymphomaor lymphoma
Normal to low 25-vit DNormal to low 25-vit D
HighHigh 1,25-vit D1,25-vit D
High 25-vit DHigh 25-vit D
and 1,25-vit Dand 1,25-vit D
Vitamin DVitamin Dintoxicationintoxication
Normal 25-vit DNormal 25-vit Dand 1,25-vit Dand 1,25-vit D
MalignancyMalignancyEndocrine causeEndocrine causeDrugsDrugs
ImmobilizationImmobilization
Known malignancKnown malignanc
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Localization StudiesLocalization Studies Noninvasive preoperative methodsNoninvasive preoperative methods
1.1. UltrasonographyUltrasonography2.2. Radioiodine or technetium thyroid scanRadioiodine or technetium thyroid scan3.3. Thallium-technetium scintigraphyThallium-technetium scintigraphy4.4. Technetium-99m sestamibi scintigraphyTechnetium-99m sestamibi scintigraphy5.5. Computed tomography scanComputed tomography scan6.6. Magnetic resonance imagingMagnetic resonance imaging
Invasive preoperative methodsInvasive preoperative methods1.1. Fine-needle aspirationFine-needle aspiration2.2. Selective arteriography or digital subtraction angiographySelective arteriography or digital subtraction angiography3.3. Selective venous sampling for parathyroid hormone assaySelective venous sampling for parathyroid hormone assay4.4. Arterial injection of selenium-ethionineArterial injection of selenium-ethionine
Intraoperative MethodsIntraoperative Methods1.1. Intraoperative ultrasonographyIntraoperative ultrasonography2.2.
Toluidine blue or methylene blueToluidine blue or methylene blue3.3. Urinary adenosine monophosphateUrinary adenosine monophosphate4.4. Quick parathyroid hormone intraoperativeQuick parathyroid hormone intraoperative
S ibi T h i 99
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Sestamibi-Technetium 99mSestamibi-Technetium 99m
ScintographyScintography Sestamibi taken up mitochondria of parathyroid cells greater thanSestamibi taken up mitochondria of parathyroid cells greater than
surrounding parenchyma.surrounding parenchyma. Inject 20 to 25 millicuries of technetium-99m sestamibi. ImagesInject 20 to 25 millicuries of technetium-99m sestamibi. Images
obtained at 10-15 minutes then 2-3 hours after the injection.obtained at 10-15 minutes then 2-3 hours after the injection. Late phase preferable for detecting parathyroid adenomas, asLate phase preferable for detecting parathyroid adenomas, as
thyroid nodules clear uptake faster than do parathyroid neoplasms.thyroid nodules clear uptake faster than do parathyroid neoplasms. Sensitivity (solitary adenoma) ~100%, Specificity ~90%.Sensitivity (solitary adenoma) ~100%, Specificity ~90%. False-positive:False-positive:
1.1. Solid thyroid nodules (adenomas)Solid thyroid nodules (adenomas)2.2. Hurthle cell carcinomaHurthle cell carcinoma3.3. Malignant thyroid lymph node metastasesMalignant thyroid lymph node metastases
4.4. No false-positive with cystic lesions of the thyroid glandNo false-positive with cystic lesions of the thyroid gland
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Continued.Continued.
Tc-99mTc-99mSestamibiSestamibi
suggestedsuggestedparathyroidparathyroidadenoma in Radenoma in R
inferior pole ofinferior pole ofthyroid gland.thyroid gland.
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Primary HPT - DiagnosisPrimary HPT - Diagnosis
Persistent Hypercalcaemia.Persistent Hypercalcaemia. Low serum phosphate.Low serum phosphate.
High normal or elevated PTHHigh normal or elevated PTHconcentration.concentration. 24h urinary Calcium excretion24h urinary Calcium excretion
Sestemebi scanSestemebi scan
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Indications for surgeryIndications for surgery
Nephrolithiasis, bone disease, andNephrolithiasis, bone disease, andneuromuscular symptoms respond well toneuromuscular symptoms respond well tosurgery.surgery.
Primary hyperparathyroidism due to adenoma isPrimary hyperparathyroidism due to adenoma iscured surgically by excision of the adenoma. Allcured surgically by excision of the adenoma. Allfour glands must be identified though!four glands must be identified though!
Primary hyperparathyriodism due to parathyroidPrimary hyperparathyriodism due to parathyroid
hyperplasia is treated with subtotalhyperplasia is treated with subtotalparathyroidectomy (3 1/2) or totalparathyroidectomy (3 1/2) or totalparathyroidectomy with autotranspantation intoparathyroidectomy with autotranspantation intothe arm.the arm.
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Surgical indications forSurgical indications forasymptomatic hyperparathyroidismasymptomatic hyperparathyroidism On initial evaluationOn initial evaluation
Markedly elevated CAMarkedly elevated CA Hx of life threateningHx of life threatening
hypercalcemia (??)hypercalcemia (??) Reduced Cr CL.Reduced Cr CL. NephrolithiasisNephrolithiasis Markedly elevatedMarkedly elevated
24hr U Ca24hr U Ca Substantially reducedSubstantially reduced
bone massbone mass
Following asymptomaticFollowing asymptomaticptpt Pt becomes symptomaticPt becomes symptomatic Ca 1-1.6 mg/100 ml aboveCa 1-1.6 mg/100 ml above
normalnormal NephrolithiasisNephrolithiasis Decline in bone massDecline in bone mass Neuro or psych problemsNeuro or psych problems
Pt desire to fix.Pt desire to fix.
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HYPERCALCEMIAHYPERCALCEMIATREATMENTTREATMENT
Acute treatment for any etiologyAcute treatment for any etiology Volume repletion with NS to increaseVolume repletion with NS to increase
Ca++ filtrationCa++ filtration Can add lasix (promotes calciumCan add lasix (promotes calcium
excretion) when volume repleteexcretion) when volume replete
More long term therapy is dependent onMore long term therapy is dependent onthe etiologythe etiology
TREATMENT OF HYPERCALCEMIATREATMENT OF HYPERCALCEMIA
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TREATMENT OF HYPERCALCEMIATREATMENT OF HYPERCALCEMIA
GENERAL PRINCIPLESGENERAL PRINCIPLES
Virtually all patients with severe andVirtually all patients with severe andsymptomatic hypercalcemia will be volumesymptomatic hypercalcemia will be volumedepleted. Volume replacement should be starteddepleted. Volume replacement should be started
first.first. Acute therapy of hypercalcemia is usuallyAcute therapy of hypercalcemia is usually
effective. Long term therapy is moreeffective. Long term therapy is moreproblematic.problematic.
TREATMENTS FOR HYPERCALCEMIATREATMENTS FOR HYPERCALCEMIA
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TREATMENTS FOR HYPERCALCEMIATREATMENTS FOR HYPERCALCEMIA
GENERAL SPECIFIC
Vol. Expansion (saline) I.V. Pamidronate
Diuresis (Lasix) I.V. Zoledronate
Mobilization Calcitonin
Restrict PO Calcium Gallium nitrate
Dialysis Plicamycin
Glucocorticoids
PhosphateIndomethacin
Antitumor Therapy
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Surgical ManagementSurgical Management
Clinical indicators for surgery*Clinical indicators for surgery*2.2. Serum calcium is >1.0 mg/dL above the upper limit ofSerum calcium is >1.0 mg/dL above the upper limit of
normal.normal.3.3. Creatinine clearance is reduced >30% for age in theCreatinine clearance is reduced >30% for age in the
absence of another cause.absence of another cause.4.4. Twenty-four hour urinary calcium is >400 mg/dL.Twenty-four hour urinary calcium is >400 mg/dL.5.5. Patients are younger than 50 years of age.Patients are younger than 50 years of age.6.6. Bone mineral density measurement at the lumbar spine,Bone mineral density measurement at the lumbar spine,
hip, or distal radius is reduced >2.5 standard deviationship, or distal radius is reduced >2.5 standard deviations
(by T score).(by T score).7.7. Patients request surgery, or patients are unsuitable forPatients request surgery, or patients are unsuitable forlong-term surveillance.long-term surveillance.
*Consensus conference held by the National Institutes of Health in
2002
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Continued.Continued.
AdenomaAdenoma
2.2. Directed unilateral cervical exploration.Directed unilateral cervical exploration.
3.3.
Curative in >95% of patientsCurative in >95% of patients4.4. Preoperative localization withPreoperative localization withtechnetium-99m sestamibi + IOPTHtechnetium-99m sestamibi + IOPTH
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Continued.Continued.
MEN 1MEN 1
1.1. Subtotal vs. total with autotransplantation.Subtotal vs. total with autotransplantation.
Men 2a-Men 2a-1.1. 100% cure rate with no recurrences whether100% cure rate with no recurrences whether
total parathyroidectomy, subtotaltotal parathyroidectomy, subtotalparathyroidectomy, or excision of enlargedparathyroidectomy, or excision of enlargedglands performed.glands performed.
2.2. R/O pheochromocytoma prior to OR tripR/O pheochromocytoma prior to OR trip(hypertensive crisis).(hypertensive crisis).
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Continued.Continued.
Non-MEN familial hyperparathyroidismNon-MEN familial hyperparathyroidism(NMFH).(NMFH).
1.1. Subtotal or total (autotransplant) withSubtotal or total (autotransplant) with
bilateral cervical thymectomy.bilateral cervical thymectomy. Familial neonatal hyperparathyroidism.Familial neonatal hyperparathyroidism.
1.1. Total (autotransplant) + bilateralTotal (autotransplant) + bilateral
transcervical thymectomytranscervical thymectomy
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Continued.Continued.
Renal failure-induced hyperparathyroidism.Renal failure-induced hyperparathyroidism.1.1. Subtotal vs. total parathyroidectomy (autotransplant) with orSubtotal vs. total parathyroidectomy (autotransplant) with or
without cryopreservation.without cryopreservation.
Parathyroid CarcinomaParathyroid Carcinoma1.1. en bloc resection of the tumor and areas of potential localen bloc resection of the tumor and areas of potential local
invasion and/or regional metastasis (ipsilateral central neckinvasion and/or regional metastasis (ipsilateral central neckcontents including the thyroid lobe and tracheoesophagealcontents including the thyroid lobe and tracheoesophagealsoft tissues, lymphatics, and resection of soft tissues withinsoft tissues, lymphatics, and resection of soft tissues withinthe superior anterior mediastinum)the superior anterior mediastinum)
2.2. RLN, esophageal wall, or strap muscles may require sacrificeRLN, esophageal wall, or strap muscles may require sacrificeif the tumor adheres to them.if the tumor adheres to them.
3.3. Not enough data to recommend for or against chemotherapyNot enough data to recommend for or against chemotherapyor RT.or RT.
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Continued.Continued.
MIRPMIRP2.2. Preoperative administration of technetium 99m sestamibi beforePreoperative administration of technetium 99m sestamibi before
operation + intraoperative hand-held gamma probe.operation + intraoperative hand-held gamma probe.3.3. Advantages:Advantages:
Improved patient comfort postoperatively.Improved patient comfort postoperatively. Performance of ambulatory procedures.Performance of ambulatory procedures. Reduced cost.Reduced cost. Avoidance of general anesthetic.Avoidance of general anesthetic.
4.4. Disadvantages:Disadvantages:1.1. Potential for conversion to bilateral dissection in event of failedPotential for conversion to bilateral dissection in event of failed
exploration.exploration.2.2.
Patient anxiety when conversion needed (general anesthesia).Patient anxiety when conversion needed (general anesthesia).
F ili l B i H l iF ili l B i H l i
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Familial Benign HypercalcaemiaFamilial Benign Hypercalcaemia(FBH).(FBH).
Familial, AD. Family history important.Familial, AD. Family history important. Often come to light after failedOften come to light after failed
parathyroidectomyparathyroidectomy Benign. Asymptomatic.Benign. Asymptomatic. Low urinary calcium excretion.Low urinary calcium excretion.
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Primary HPT- treatmentPrimary HPT- treatment
Parathyroidectomy.Parathyroidectomy. Serum calcium should be normal withinSerum calcium should be normal within
24h.24h. Postoperative hypocalcaemia.Postoperative hypocalcaemia. Recurrent laryngeal nerve injury.Recurrent laryngeal nerve injury.
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TREATMENTTREATMENT
Hypercalcemia of malignancyHypercalcemia of malignancy IV PamidronateIV Pamidronate
Inhibits osteoclastic bone resorptionInhibits osteoclastic bone resorption
Takes 2-4 days to see full effectTakes 2-4 days to see full effect Must be given every 30-60 days toMust be given every 30-60 days to
prevent recurrence of hypercalcemiaprevent recurrence of hypercalcemia CalcitoninCalcitonin
Inhibits osteoclast actionInhibits osteoclast action
See an effect within 24 hrsSee an effect within 24 hrs
Effect wears off within 2-3 days due toEffect wears off within 2-3 days due totachyphalaxistachyphalaxis
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TREATMENTTREATMENT
Increased 1-hydroxylation of vitamin D due toIncreased 1-hydroxylation of vitamin D due togranulomatous diseasegranulomatous disease High dose steroids are effective inHigh dose steroids are effective in
sarcoidosissarcoidosis Questionable whether steroids are effective inQuestionable whether steroids are effective in
other granulomatous diseasesother granulomatous diseases
H l i f liHypercalcaemia of malignancy
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Hypercalcaemia of malignancyHypercalcaemia of malignancy
Carcinomas of breast, lung, head andCarcinomas of breast, lung, head andneck,renal.neck,renal.
Usually squamous carcinomas.Usually squamous carcinomas. PTHrP increasedPTHrP increased PTH normalPTH normal
Low serum albumin, high ESR, anemia.Low serum albumin, high ESR, anemia. Myeloma, local bone resorption.Myeloma, local bone resorption.
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SarcoidosisSarcoidosis
Small numbers of patients with sarcoidosisSmall numbers of patients with sarcoidosisdevelop hypercalcaemia.develop hypercalcaemia.
May develop after prolonged sunMay develop after prolonged sun
exposure.exposure. 1,25 diOH Vit D high, prodiced by alveolar1,25 diOH Vit D high, prodiced by alveolar
macrophages. PTH is normal.macrophages. PTH is normal. Corrected by SteroidsCorrected by Steroids
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ThyrotoxicosisThyrotoxicosis
Severe thyrotoxicosisSevere thyrotoxicosis Increased calcium release from boneIncreased calcium release from bone
(Thyroxine acts on bone)(Thyroxine acts on bone)
PTH is normalPTH is normal Takes 4-6 weeks to resolve withTakes 4-6 weeks to resolve with
antithyroid treatmentantithyroid treatment
Persistent hypercalcaemia usually meansPersistent hypercalcaemia usually meansconcomitant HPT.concomitant HPT.
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Band KeratopathyBand Keratopathy
HYPOCALCEMIAHYPOCALCEMIA
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HYPOCALCEMIA:HYPOCALCEMIA:ETIOLOGIESETIOLOGIES
HYPOPARATHYROID STATES:HYPOPARATHYROID STATES: AUTOIMMUNEAUTOIMMUNE CONGENITALCONGENITAL
DIGEORGE SYNDROMEDIGEORGE SYNDROME
POSTSURGICALPOSTSURGICAL SEVERE MAGNESIUM DEFICIENCYSEVERE MAGNESIUM DEFICIENCY NECK IRRADIATIONNECK IRRADIATION INFILTRATIVEINFILTRATIVE
HEMOCHROMATOSISHEMOCHROMATOSIS
SARCOIDOSISSARCOIDOSIS
WILSONS DISEASEWILSONS DISEASE HUNGRY BONE SYNDROMEHUNGRY BONE SYNDROME
HYPOCALCEMIAHYPOCALCEMIA
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HYPOCALCEMIA:HYPOCALCEMIA:ETIOLOGIESETIOLOGIES
NONHYPOPARATHYROID STATESNONHYPOPARATHYROID STATES VITAMIN D DEFICIENCYVITAMIN D DEFICIENCY
LACK OF SUNLIGHT EXPOSURELACK OF SUNLIGHT EXPOSURE
DIETARY LACKDIETARY LACK
MALABSORPTIONMALABSORPTION UPPER GI SURGERYUPPER GI SURGERY
LIVER DISEASELIVER DISEASE
RENAL DISEASERENAL DISEASE
ANTICONVULSANTSANTICONVULSANTS
VITAMIN D DEPENDENT RICKETS (1VITAMIN D DEPENDENT RICKETS (1-HYDROXYLASE-HYDROXYLASEDEFICIENCY)DEFICIENCY)
HYPOCALCEMIAHYPOCALCEMIA
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HYPOCALCEMIA:HYPOCALCEMIA:ETIOLOGIESETIOLOGIES
NONHYPOPARATHYROID STATESNONHYPOPARATHYROID STATES PARATHYROID HORMONE STATESPARATHYROID HORMONE STATES
PSEUDOHYPOPARATHYROIDISMPSEUDOHYPOPARATHYROIDISM
SEVERE MAGNESIUM DEFICIENCYSEVERE MAGNESIUM DEFICIENCY
VITAMIN D RESISTANCEVITAMIN D RESISTANCE DRUGSDRUGS
BISPHOSPHONATESBISPHOSPHONATES
CISPLATINUMCISPLATINUM
KETACONAZOLEKETACONAZOLE
PENTAMIDINEPENTAMIDINE
FOSCARNETFOSCARNET
HYPOCALCEMIAHYPOCALCEMIA
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HYPOCALCEMIA:HYPOCALCEMIA:ETIOLOGIESETIOLOGIES
MISCELLANEOUSMISCELLANEOUS ACUTE PANCREATITISACUTE PANCREATITIS MASSIVE TUMOR LYSISMASSIVE TUMOR LYSIS
OSTEOBLASTIC METASTASESOSTEOBLASTIC METASTASES PHOSPHATE INFUSIONPHOSPHATE INFUSION MULTIPLE CITRATED BLOOD TRANSFUSIONSMULTIPLE CITRATED BLOOD TRANSFUSIONS ACUTE RHABDOMYOLYSISACUTE RHABDOMYOLYSIS
ACUTE SEVERE ILLNESSACUTE SEVERE ILLNESS
MANEFESTATIONS OFMANEFESTATIONS OF
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MANEFESTATIONS OFMANEFESTATIONS OFHYPOCALCEMIAHYPOCALCEMIA
NEUROLOGICNEUROLOGIC PERIPHERAL IRRITABILITY (TETANY)PERIPHERAL IRRITABILITY (TETANY)
+CHVOSTEKS AND TROUSSEAUS SIGNS+CHVOSTEKS AND TROUSSEAUS SIGNS CENTRAL IRRITABILITY (SEIZURES)CENTRAL IRRITABILITY (SEIZURES)
INTRACRANIAL CALCIFICATIONS (BASAL GANGLIA)INTRACRANIAL CALCIFICATIONS (BASAL GANGLIA) PAPILLEDEMAPAPILLEDEMA MENTAL CHANGESMENTAL CHANGES
CATARACTSCATARACTS ABNORMAL DENTITIONABNORMAL DENTITION
CARDIOVASCULARCARDIOVASCULAR PROLONGED Q-T INTERVALPROLONGED Q-T INTERVAL CHF, DIGITALIS RESISTANCECHF, DIGITALIS RESISTANCE
HYPOCALCEMIAHYPOCALCEMIA
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HYPOCALCEMIA:HYPOCALCEMIA:SIGNSSIGNS
TREATMENT OF HYPOCALCEMIATREATMENT OF HYPOCALCEMIA
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TREATMENT OF HYPOCALCEMIATREATMENT OF HYPOCALCEMIA
ACUTE HYPOCALCEMIAACUTE HYPOCALCEMIA ASX PATIENT WITH MILD HYPOCALCEMIA (7.5-8.5 MG/DL): WATCH;ASX PATIENT WITH MILD HYPOCALCEMIA (7.5-8.5 MG/DL): WATCH;
MAY USE ORAL CALCIUM (500 TO 1000 MG PER DAY ELEMENTALMAY USE ORAL CALCIUM (500 TO 1000 MG PER DAY ELEMENTALCALCIUM)CALCIUM)
PATIENT WITH TETANY MUST TREAT WITH PARENTERAL CALCIUMPATIENT WITH TETANY MUST TREAT WITH PARENTERAL CALCIUM PATIENT WITH SERUM CALCIUM < 7.5 OR WITH SXS, TREAT WITHPATIENT WITH SERUM CALCIUM < 7.5 OR WITH SXS, TREAT WITH
PARENTERAL CALCIUMPARENTERAL CALCIUM USE CALCIUM GLUCONATE (90 MG/ 100 ML)USE CALCIUM GLUCONATE (90 MG/ 100 ML)
1 TO 2 AMPULES IN 50 TO 100 ML OF 5% DEXTROSE (180 MG1 TO 2 AMPULES IN 50 TO 100 ML OF 5% DEXTROSE (180 MGELEMENTAL CALCIUM) OVER 5 TO 10 MINELEMENTAL CALCIUM) OVER 5 TO 10 MIN
FOLLOW WITH 15 TO 20 MG/KG ELEMENTAL CALCIUM OVER 4FOLLOW WITH 15 TO 20 MG/KG ELEMENTAL CALCIUM OVER 4TO 6 HRTO 6 HR
WILL RAISE SERUM CALCIUM BY 2-3 MG/DLWILL RAISE SERUM CALCIUM BY 2-3 MG/DL
IF HYPOCALCEMIA IS LIKELY TO PERSIST, INITIATE ORALIF HYPOCALCEMIA IS LIKELY TO PERSIST, INITIATE ORALCALCIUM (1-2 GM PER DAY) WITH CALCITRIOL (O.5-1.0CALCIUM (1-2 GM PER DAY) WITH CALCITRIOL (O.5-1.0 g/day)g/day)
MONITOR SERUM MAGNESIUM AND REPLACE IF NECESSARYMONITOR SERUM MAGNESIUM AND REPLACE IF NECESSARY
TREATMENT OF HYPOCALCEMIATREATMENT OF HYPOCALCEMIA
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TREATMENT OF HYPOCALCEMIATREATMENT OF HYPOCALCEMIA
CHRONIC HYPOCALCEMIACHRONIC HYPOCALCEMIA START SUPPLEMENTAL ORAL CALCIUM (1-2START SUPPLEMENTAL ORAL CALCIUM (1-2
GM PER DAY) AND A VITAMIN DGM PER DAY) AND A VITAMIN DPREPARATION (ERGOCALCIFEROL 50,000PREPARATION (ERGOCALCIFEROL 50,000UNITS ONCE PER WEEK TO DAILY; ORUNITS ONCE PER WEEK TO DAILY; ORROCALTROL 0.5-1.0ROCALTROL 0.5-1.0 ICROGRAMS PER DAY)ICROGRAMS PER DAY)
MAINTAIN SERUM CALCIUM IN THE LOWMAINTAIN SERUM CALCIUM IN THE LOWNORMAL RANGE BECAUSE OF THE RISK OFNORMAL RANGE BECAUSE OF THE RISK OFHYPERCALCIURIA AND NEPHROLITHIASISHYPERCALCIURIA AND NEPHROLITHIASIS
C li ti f th idComplications of parathyroid surgery
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Complications of parathyroid surgery.Complications of parathyroid surgery.
HypocalcemiaHypocalcemia Persistent hypercalcemiaPersistent hypercalcemia Recurrent laryngeal nerve injuryRecurrent laryngeal nerve injury