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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 97-100

Primary hyperparathyroidism: diagnostics and surgical management


1 Department of General Surgery, Regional Specialist Hospital, Częstochowa, Poland
2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland

Date of Submission17-May-2020
Date of Acceptance17-May-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Dr. Leszek Sulkowski
Department of General Surgery, Regional Specialist Hospital, ul. Bialska 104/118, 42-218 Częstochowa.
Poland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.MGMJ_32_20

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  Abstract 

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

How to cite this URL:
Sulkowski L, Matyja M. Primary hyperparathyroidism: diagnostics and surgical management. MGM J Med Sci [serial online] 2020 [cited 2020 Sep 29];7:97-100. Available from: http://www.mgmjms.com/text.asp?2020/7/2/97/287166




  Introduction Top


The most common cause of hypercalcemia is hyperparathyroidism. Its predominant form is an adenoma of the single parathyroid gland (PTG).[1],[2] It is predominantly revealed in the postmenopausal age.[3] The preoperative localization of enlarged PTG is crucial for a successful surgery.[2],[4],[5] Diagnostic modalities for patients with primary hyperparathyroidism (PHPT) include ultrasounds, computed tomography (CT) scanning, and sestamibi radionuclide scanning (99mTc-MIBI scintigraphy).[2],[4],[6] Parathyroidectomy is recommended definitive treatment modality despite PHPT advancement.[3],[7]


  Materials and methods Top


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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Figure 4: Neck wound closed over a suction drainage

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Histopathological examination of the tumor proved the presence of PTG adenoma and multinodular goiter in the right thyroid lobe.


  Discussion Top


PHPT manifests predominantly as adenoma in a single, hyperfunctioning PTG with autonomous oversecretion of parathormone.[2],[7][8][9] It is predominantly revealed in women of postmenopausal age, and is the most common cause of hypercalcemia.[1],[3] 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.[10],[11],[12],[13],[14]

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.[5][6][7] Diagnostic modalities include ultrasounds [Figure 1A and B], CT scanning, and sestamibi radionuclide scanning [Figure 2A–C].[2],[4],[6] The positive correlation between intact parathormone and MIBI scintigraphy is worth noting.[15] 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.[4] 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.[5]

Patients with PHPT require parathyroidectomy for definitive management.[7] 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.[2] Parathyroidectomy is recommended for each stage of PHPT, despite the severity of hypercalcemia, level of parathormone, and organ involvement.[3]

Significant bone remineralization is observed postoperatively, which depends on PHPT severity, age, and renal function.[16] Approximately 13% of patients’ hungry bone syndrome is revealed postoperatively as a result of successful parathyroidectomy.[17]

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.[17] Robotic parathyroidectomy is a long-lasting and a much more expensive procedure, but the cosmetic effect is much better.[18] Another novelly described approach for a very limited group of patients is transoral endoscopic parathyroidectomy.[7] The video-assisted neck exploration is described to assure better visualization of PTGs.[9] However, regardless of surgical technique, preoperative visualization of PTGs remains crucial.[2],[4],[5]


  Conclusion Top


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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tokmak H, Demirkol MO, Alagöl F, Tezelman S, Terzioglu T. Clinical impact of SPECT-CT in the diagnosis and surgical management of hyper-parathyroidism. Int J Clin Exp Med 2014;7:1028-34.  Back to cited text no. 1
    
2.
El-Hady HA, Radwan HS. Focused parathyroidectomy for single parathyroid adenoma: A clinical account of 20 patients. Electron Physician 2018;10:6974-80.  Back to cited text no. 2
    
3.
Bilezikian JP. Primary hyperparathyroidism. J Clin Endocrinol Metab 2018;103:3993-4004.  Back to cited text no. 3
    
4.
Al-Kurd A, Levit B, Assaly M, Mizrahi I, Mazeh H, Mekel M. Preoperative localization modalities in primary hyperparathyroidism: Correlation with postoperative cure. Surgery 2018;164:136-8.  Back to cited text no. 4
    
5.
Tay YD, Yeh R, Kuo JH, McManus C, Lee JA, Bilezikian JP. Pre-operative localization of abnormal parathyroid tissue by 99mTc-sestamibi in primary hyperparathyroidism using four-quadrant site analysis: An evaluation of the predictive value of vitamin D deficiency. Endocrine 2018;60:36-45.  Back to cited text no. 5
    
6.
Sulkowski L, Matyja M, Pasternak A. Surgical management of secondary hyperparathyroidism in end-stage kidney disease: A case report. MGM J Med Sci 2018;5:197-9.  Back to cited text no. 6
    
7.
Bhargav PR, Sabaretnam M, Amar V, Devi NV. Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A south Indian experience. J Minim Access Surg 2019;15:119-23.  Back to cited text no. 7
    
8.
Asseeva P, Paladino NC, Guerin C, Castinetti F, Vaillant-Lombard J, Abdullah AE, et al. Value of 123I/99mTc-sestamibi parathyroid scintigraphy with subtraction SPECT/CT in primary hyperparathyroidism for directing minimally invasive parathyroidectomy. Am J Surg 2019;217:108-13.  Back to cited text no. 8
    
9.
Alesina PF, Meier B, Hinrichs J, Mohmand W, Walz MK. Enhanced visualization of parathyroid glands during video-assisted neck surgery. Langenbecks Arch Surg 2018;403:395-401.  Back to cited text no. 9
    
10.
Sułkowski L, Matyja M, Pasternak A. Lipectomy technique as a second-stage procedure for primarily matured, deep outflow vein in obese individuals. Indian J Nephrol 2018;28:320-2.  Back to cited text no. 10
    
11.
Sulkowski L, Matyja M, Pasternak A. Salvage technique for complicated hemodialysis patients with central venous occlusion. J Postgrad Med Edu Res 2018;52:152-4.  Back to cited text no. 11
    
12.
Ejlsmark-Svensson H, Bislev LS, Rolighed L, Sikjaer T, Rejnmark L. Predictors of renal function and calcifications in primary hyperparathyroidism: A nested case-control study. J Clin Endocrinol Metab 2018;103:3574-83.  Back to cited text no. 12
    
13.
Sulkowski L, Matyja M, Walocha JA, Pasternak A. Satisfaction with life among dialyzed patients: A Cantril ladder survey. MGM J Med Sci 2018;5:6-11.  Back to cited text no. 13
    
14.
Sułkowski L, Matyja M, Pasternak A, Matyja A. WHOQOL-BREF survey of quality of life among dialyzed end-stage renal disease patients. Arch Med Sci Civil Dis 2018;3:112-20.  Back to cited text no. 14
    
15.
Cordes M, Dworak O, Papadopoulos T, Coerper S, Kuwert T. MIBI scintigraphy of parathyroid adenomas: Correlation with biochemical and histological markers. Endocr Res 2018;43:141-8.  Back to cited text no. 15
    
16.
Sitges-Serra A, García L, Prieto R, Peña MJ, Nogués X, Sancho JJ. Effect of parathyroidectomy for primary hyperparathyroidism on bone mineral density in postmenopausal women. Br J Surg 2010;97:1013-9.  Back to cited text no. 16
    
17.
Jakubauskas M, Beiša V, Strupas K. Risk factors of developing the hungry bone syndrome after parathyroidectomy for primary hyperparathyroidism. Acta Med Litu 2018;25:45-51.  Back to cited text no. 17
    
18.
Arora A, Garas G, Tolley N. Robotic parathyroid surgery: Current perspectives and future considerations. ORL J Otorhinolaryngol Relat Spec 2018;80:195-203.  Back to cited text no. 18
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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