Hyperparathyroidism and Hypercalcemia

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Hyperparathyroidism and Hypercalcemia

• Julie E. Park
• April 5, 2005
• Tuesday Conference

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Anatomy

• 4 glands (2-6)
• 1 x 3 x 5 mm
• 30-50 mg

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Anatomy

• Superior
• Post or lateral to upper thyroid pole
• Sup or inf thyroid a.
• Post to RLN
• Inferior
• Inf, post, or immediately lat lower thyroid pole
• Inf thyroid a.
• Ant to RLN

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Embryology

• Branchial pouches
• 3 inferior parathyroid and thymus
• 4 superior parathyroid and thyroid

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Ectopic locations parathyroid

• Thymus
• Thyrothymic ligament
• Tracheoesophageal groove
• Retroesophageal space
• Carotid sheath
• Intrathyroid

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Diagnosis

• Hypercalcemia
• Elevated PTH

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Parathyroid hormone

• Regulates serum calcium
• 84 amino acid polypeptide
• N-terminal frag biologically active
• C- terminal frag inactive
• Intact PTH half-life 2 to 5 minutes

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Differential Diagnosis

• HPT
• Malignancy
• Vit A or Vit D intoxication
• Thiazide diurectics
• Hyperthyroidism
• Milk-alkali syndrone
• Sarcoidosis/granulomatous diseases
• Familial hypocalciuric hypercalcemia
• Immobilization
• Pagets disease
• Lithium
• Addisonian crisis
• Idiopathic hypercalcemia of infancy

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Skeletal manifestations
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Pathophysiology

• Primary
• Adenoma
• Hyperplasia
• Carcinoma
• Secondary
• Hyperplasia
• chronic renal failure, malabsorbtion
• Tertiary
• Autonomous secondary hyperparthyroidism
• Renal transplant in HD dependent pt

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Primary HPT

• Excess secretion of PTH from one or more
  parathyroid glands
• 11000
• 1.5100 in elderly
• Ave age 55
• 41 female to male ratio

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Primary HPT Associated pathology

• PUD
• Pancreatitis
• HTN
• MEN Syndrome
• Familial HPT
• Gout
• Previous RT to neck
• Band keratopathy

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Primary HPT

• Adenoma 90
• Hyperplasia 8
• Mult Adenomas 2
• Carcinoma lt1

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Multiple Endocrine Neoplasia

• MEN I
• Parathyroid/Pancreas/Pituitary
• MEN IIa
• Medullary/ Pheo/ Parathyroid

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Indications for surgery for secondary HPT

• Renal Osteodystrophy
• Pruritis
• Ectopic calcifications

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Surgical Management

• Conventional
• 4 gland exploration
• Minimally Invasive
• MIP

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Conventional

• Exploration 4 glands
• Cervical incision
• General Anesthesia

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Adenoma

• 3 normal plus 1 enlarged
• Superior gland
• 40 migrate to retropharyngeal or paraesophageal
  site or beneath thyroid sheath
• Inferior gland
• Can be in thymus, lower third thyroid gland or
  within carotid sheath

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Hyperplasia

• All enlarged
• Subtotal parathyroidectomy
• 40 mg portion of most normal appearing gland
• Mark w/ titanium clip
• Total w/ heterotopic transplantation
• Nondominant forearm
• /- cryopreservation of parathyroid tissue

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Absent 4th gland

• Explored and found 3 normal glands
• On side of missing gland
• Explore neck above superior pole
• Thymectomy
• Intra op US/PTH
• Thyroid lobectomy
• Explore branches of inf thyroid artery
• No sternotomy
• Post op localization

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Minimally invasive

• Preoperative localization
• Limited incision
• Poss local anesthesia
• Intraop PTH
• Decrease by 50 in 5 minutes

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Persistent or recurrent hyperparathyroidism

• Unrecognized second adenoma
• 8 reexplorations
• Inadequately resected hyperplasia
• 37 reexplorations
• Inadvertant autotransplanted tissue
• Residual or metastatic carcinoma
• rare

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Persistent or recurrent hyperparathyroidism

• Confirm initial diagnosis
• Localize
• Sestamibi scan
• CT
• Selective venous sampling
• Reoperation

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Non-operative ablation

• Angiography and embolization
• US guided alcohol ablation

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Postoperative Management

• Nerve injury
• Hematoma
• Infection
• Hypocalcemia

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