|Year : 2020 | Volume
| Issue : 2 | Page : 97-100
Primary hyperparathyroidism: diagnostics and surgical management
Leszek Sulkowski1, Maciej Matyja2
1 Department of General Surgery, Regional Specialist Hospital, Częstochowa, Poland
2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
|Date of Submission||17-May-2020|
|Date of Acceptance||17-May-2020|
|Date of Web Publication||19-Jun-2020|
Dr. Leszek Sulkowski
Department of General Surgery, Regional Specialist Hospital, ul. Bialska 104/118, 42-218 Częstochowa.
Source of Support: None, Conflict of Interest: None
Primary hyperparathyroidism is an endocrinological pathology of parathyroid glands. Its predominant form is a single parathyroid gland adenoma. We present a case of a 53-year-old patient, who was referred with primary hyperparathyroidism. She underwent ultrasound and sestamibi radionuclide scanning, and was offered surgery. The postoperative histopathological examination proved the presence of parathyroid gland adenoma. Patients managed with primary hyperparathyroidism require preoperative localization of enlarged, usually single parathyroid glands. Diagnostic modalities include ultrasounds, computed tomography scanning, and sestamibi radionuclide scanning. Parathyroidectomy is a recommended treatment modality for each stage of primary hyperparathyroidism, despite organ involvement, severity of hypercalcemia, and parathormone concentration. Significant bone remineralization is observed postoperatively. Preoperative localization of the enlarged parathyroid gland is crucial. Primary hyperparathyroidism requires surgery for definitive treatment. Surgery, although challenging, leads to a cure.
Keywords: 99mTc-MIBI scintigraphy, parathormone, parathyroid gland, parathyroidectomy, primary hyperparathyroidism, sestamibi radionuclide scanning
|How to cite this article:|
Sulkowski L, Matyja M. Primary hyperparathyroidism: diagnostics and surgical management. MGM J Med Sci 2020;7:97-100
| Introduction|| |
The most common cause of hypercalcemia is hyperparathyroidism. Its predominant form is an adenoma of the single parathyroid gland (PTG)., It is predominantly revealed in the postmenopausal age. The preoperative localization of enlarged PTG is crucial for a successful surgery.,, Diagnostic modalities for patients with primary hyperparathyroidism (PHPT) include ultrasounds, computed tomography (CT) scanning, and sestamibi radionuclide scanning (99mTc-MIBI scintigraphy).,, Parathyroidectomy is recommended definitive treatment modality despite PHPT advancement.,
| Materials and methods|| |
We present a case of a 53-year-old patient with PHPT, who was referred to the Department of Surgery. The patient underwent ultrasound, which revealed a tumor 9 × 12 × 15mm in size, located backward from the right thyroid lobe [Figure 1]A and B. The Tc-99m scintigraphy along with the 99mTc-MIBI scintigraphy and subtraction scan revealed an area of radionuclide absorption on the right side of the neck [Figure 2]A–C. The area of radionuclide absorption pointed to the most likely location of PTG adenoma and corresponded to the location of the tumor visualized in the ultrasound [Figure 1]A and B.
|Figure 1: Preoperative ultrasound examination of the neck (arrows—adenoma of the right inferior parathyroid gland, arrowheads—right lobe of the thyroid gland). (A) Transverse plane. (B) Longitudinal plane|
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|Figure 2: Sestamibi radionuclide neck scanning. (A) Tc-99m scintigraphy, activity 110 MBq. (B) 99mTc-MIBI scintigraphy, activity 740 MBq. (C) Subtraction B−A scan|
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The patient was offered surgery under general anesthesia. The neck was surgically inspected with a standard transverse skin incision. The thyroid gland was exposed [Figure 3, arrowheads]. Tumor located backward from the lower pole of the right thyroid lobe was localized and excised [Figure 3, arrows]. The right thyroid lobe along with the isthmus was excised due to nodules revealed both in preoperative ultrasounds and intraoperatively. Wounds were typically closed over suction drainage [Figure 4]. The postoperative course was uneventful, and the patient was discharged from the hospital on the second postoperative day.
|Figure 3: Surgical neck exploration (white arrows—adenoma of the right inferior parathyroid gland, white arrowheads—right lobe of the thyroid gland, black arrows—right inferior thyroid artery and vein, and black arrowheads—nodule of the right thyroid lobe)|
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Histopathological examination of the tumor proved the presence of PTG adenoma and multinodular goiter in the right thyroid lobe.
| Discussion|| |
PHPT manifests predominantly as adenoma in a single, hyperfunctioning PTG with autonomous oversecretion of parathormone., It is predominantly revealed in women of postmenopausal age, and is the most common cause of hypercalcemia., In some PHPT cases, renal calcifications or impaired renal function is found, although, in contrast to secondary hyperparathyroidism, renal disease is not associated with PHPT.,,,,
Preoperative PTG localization [Figures 1A and B and 2A–C] is obligatory to minimize surgical trauma, duration of surgery, and the rate of PTG adenomas not localized properly during the surgery. Diagnostic modalities include ultrasounds [Figure 1A and B], CT scanning, and sestamibi radionuclide scanning [Figure 2A–C].,, The positive correlation between intact parathormone and MIBI scintigraphy is worth noting. It is reported in the literature that the ultrasounds performed by the surgeon are superior over both ultrasounds performed by the radiologist and 99mTc-MIBI scintigraphy. Therefore, an ultrasound neck examination performed by the surgeon who will perform parathyroidectomy is obligatory in our department [Figure 1]. We also require a radionuclide scan in each case [Figure 2A–C]. It is pointed in the literature that the more precise the preoperative localization of PTG adenoma, the less invasive the surgical parathyroidectomy.
Patients with PHPT require parathyroidectomy for definitive management. The goal is to achieve adenoma resection. When enlarged PTG is precisely localized with ultrasounds and radionuclide scanning, the focused parathyroidectomy with a single PTG resection is justifiable. Parathyroidectomy is recommended for each stage of PHPT, despite the severity of hypercalcemia, level of parathormone, and organ involvement.
Significant bone remineralization is observed postoperatively, which depends on PHPT severity, age, and renal function. Approximately 13% of patients’ hungry bone syndrome is revealed postoperatively as a result of successful parathyroidectomy.
One of the novelties described in the literature is robotic parathyroid surgery. In selected patients, when PTGs are properly localized and the instruments are available, minimally invasive techniques allow minimal exploration of the neck while maintaining the effectiveness of parathyroidectomy. Robotic parathyroidectomy is a long-lasting and a much more expensive procedure, but the cosmetic effect is much better. Another novelly described approach for a very limited group of patients is transoral endoscopic parathyroidectomy. The video-assisted neck exploration is described to assure better visualization of PTGs. However, regardless of surgical technique, preoperative visualization of PTGs remains crucial.,,
| Conclusion|| |
PHPT requires surgery for definitive treatment. Preoperative localization of enlarged PTG limits injury to surrounding tissues, caused by extensive surgical exploration, and is crucial for surgery planning. Surgery, although challenging, leads to a cure.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]