basics of diagnosis and management of primary hyperparathyroidism

1. Management of primary
hyperparathyroidism
8th semester
26.10.2022
Dr. Ankita Singh
Assistant Professor
Department of Surgery

2. Diagnosis:
Clinical- Sign & Symptoms
Investigations- Biochemical & Imaging

3. Diagnosis: Clinical
• Presentation- mc: sporadic, 50-60s, F>>M ; symptomatic
• Bones
• Osteitis fibrosa cystica, Brown tumours-long bones, subperiosteal bone resorption, distal
tapering of clavicles, ‘salt & pepper’ erosions- skull, osteopenia- radius, L spine reduction
• Stones
• Urinary stones, nephrocalcinosis
• Abdominal groans
• Hypercalcemia induced ileus
• Psychic overtones
• Depression
• Neuro-muscular dysfunction and muscle weakness
• Mild memory impairment
• Linked to pancreatitis, hypertension, PUD, Band keratopathy

4. Diagnosis: Biochemical
• Definition-
• Hypercalcemia in presence of an unsuppressed and therefore relatively, or
absolutely elevated PTH levels
• Others
• Hypercalciuria 40%, low S. Phosphates, ± raised ALP
• Incidental diagnosis:
• Elevated total calcium OR routine assessment of bone densitometry
• Differential diagnosis????

6. Diagnosis & Management: Hypercalcemic
crisis
• T. Ca >3.5mmol/L + SYMPTOMS
• Acute confusion, abdominal pain, vomiting, dehydration & anuria
• Prolonged PR interval, shortened QT interval: prior to arrhythmias
• Coma & death >4.5mmol/L
• Management:
• increasing renal excretion of calcium
• Aggressive rehydration (UO >100/hr), loop diuretics
• Reducing skeletal release of calcium
• Bisphosphonates, calcitonin, glucocorticoids
• Treatment of the underlying cause ??

7. Diagnosis: Localization
• What are we searching?
• Solitary parathyroid adenoma
• Double adenomas (2-4%)
• Multigland disease (15%)
• Localizing studies be undertaken only after biochemical confirmation
• “In my opinion, the only localizing study required in a patient with
untreated primary hyperparathyroidism is to localize an experienced
parathyroid surgeon.” John Doppman, 1986
Sporadic OR Familial

8. Diagnosis: Localization..
• Non invasive studies
• Nuclear medicine based: sestamibi scan
• Ultrasonography
• 4D CT scan & MRI
• Invasive studies

9. Sestamibi scanning
• Sestamibi- 2-methoxy-2-methylpropylisonitrile (MIBI)
• Most accurate & reliable (SN 79%, SP 90%)
• Safe & reproducible
• May image glands in ectopic positions better
• It accumulates in mitochondria, washes out differentially
• Parathyroid adenomas- high mitochondrial content & oxyphilic cells, retain
tracer- thus slow washout.
• False positive- rare, STN- Hurthle cell nodule

10. Diagnosis: Localization..
• Non invasive studies
• Nuclear medicine based: sestamibi scan
• Ultrasonography
• 4D CT scan & MRI
• Invasive studies

11. Ultrasonography
• Non-invasive, inexpensive, without radiation
• Parathyroid adenomas:
• Oval/ elongated, bi-/ multilobed hypoechoic structures
• Rarely- cystic, heterogenous
• Giant adenomas- >3cm
• Facilitate biopsy
• But operator, lesion size & location dependent
• May not differentiate small parathyroid adenoma vs. normal lymph node

12. Diagnosis: Localization..
• Non invasive studies
• Nuclear medicine based: sestamibi scan
• Ultrasonography
• 4D CT scan & MRI
• Invasive studies

13. 4D CT & MRI
• 4D CT: multiphase CT
• Anatomical & functional information
• By using precontrast, postcontrast and delayed images:
• Rapid uptake & washout- hyperfunctioning gland vs. progressive enhancement by LN
• Disadvantage- radiation dose
• MRI
• Not commonly used
• T2 weighted image: enlarged PTH gland- increased intensity
• Beneficial: reoperation, mediastinal location
• Limitation: cost, closed space, resolution poor <5mm, superior gland
obscured

14. Diagnosis: Localization..
• Non invasive studies
• Nuclear medicine based: sestamibi scan
• Ultrasonography
• 4D CT scan & MRI
• Invasive studies
• Ultrasound/ CT guided FNAC + PTH assay
• Parathyroid angiography
• Thyrocervical trunks, IMA, Carotids, superior thyroid artery
• Selective venous sampling for PTH gradient
• 2 fold drop in PTH (Sample vs. serum)
Reserved for reoperation

15. Management
• Surgical: mainstay
• Minimally invasive parathyroidectomy (Focused)
• Bilateral neck exploration
• 3.5 gland / 4 gland removal + autotransplant
• Thymectomy and resection of mediastinal adenomas
• Medical: surgically unfit
• Bisphosphonates
• HRT & selective oestrogen receptor antagonists
• Calcimimetics
Drawbacks ?

16. Surgery

17. Thank you
Any queries?