Serum Monocyte Chemokine Protein-1 Levels Before and After Parathyroidectomy in Patients with Primary Hyperparathyroidism

ObjectiveTo investigate the effects of parathyroidectomy on serum monocyte chemokine protein-1 (MCP- 1) levels in patients with primary hyperparathyroidism (PHPT).MethodsForty-three PHPT patients, age 56 ± 12 years, underwent minimally invasive parathyroidectomy. Serum samples were collected at 0 and 15 to 20 minutes after parathyroid adenoma removal. Serum samples were stored at -70°C until time of assay.ResultsIn 40 PHPT patients with a single adenoma, MCP-1 levels decreased from 342 ± 103 to 250 ± 77 pg/ mL (P < .001) 15 to 20 minutes after parathyroid adenoma removal. MCP-1 levels were positively correlated with intact parathyroid hormone (PTH) levels (R = 0.47; P < .01). In 3 PHPT patients with double parathyroid adenoma, MCP-1 levels did not decrease after removal of the first adenoma but decreased 15 to 20 minutes after second adenoma removal.ConclusionOur results provide evidence that the decrease in serum intact PTH due to minimally invasive parathyroidectomy results in an immediate decrease in serum MCP-1 levels. (Endocr Pract. 2014;20:1165-1169)     

Preoperative Calcium and Parathyroid Hormone Values Are Poor Predictors of Gland Volume and Multigland Disease in Primary Hyperparathyroidism: A Review of 2000 Consecutive Patients

ObjectiveCalcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration.MethodsTwo thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H).ResultsThere were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm³, DA = 1.43 cm³, and H = 1.27 cm³; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001).ConclusionThis is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.     

Nodule thyroïdien bénin fixant le 99mTc-MIBI

ObjectivesTo illustrate a case of intense uptake of ^99mTc-MIBI on benign thyroid nodule and to recall the mechanisms of this uptake.Case presentationA patient of 25 years old had a parathyroid scintigraphy for suspected right lower parathyroid adenoma. The exam showed intense uptake of ^99mTc-MIBI at the infero-lateral region of the right thyroid lobe. Low levels of PTH prompted to perform a thyroid scintigraphy for better diagnostic orientation. The scan revealed a large cold right basilobar thyroid nodule. The patient underwent a right loboisthmectomy. The histological analysis found a 3 cm diameter vesicular adenoma with oncocytic cells of the lower pole of right thyroid lobe.Discussion/conclusion^99mTc-MIBI is used in the imaging of hyperparathyroidism. Radiotracer uptake is correlated to the parathyroid adenoma content in oxyphil cells. These cells are rich in mitochondria and retain the ^99mTc-MIBI. This radiotracer can bind also on thyroid nodules. The specificity of this uptake for the diagnosis of malignancy is low. It is relevant to the nodule's wealth in oncocytic cells. These cells possess numerous mitochondria and can sequester ^99mTc-MIBI like parathyroid oxyphil cells.     

La concentration plasmatique de PTH permet-elle de sélectionner les patients atteints d’hyperparathyroïdie secondaire pour bénéficier de la scintigraphie double isotope MIBI (99mTc)/123I préopératoire ?

The utility of preoperative scintigraphy in case of secondary hyperparathyroidism is questioned by some authors. Obviously, an imaging modality that will detect all hyperplastic glands, including the ectopic ones, would be of interest in those patients at high risk for surgery. However, scintigraphy has a limited detection rate in some patients. We investigated whether one of the following parameters would identify a subgroup of patients in whom the detection rate would be optimal: age, gender, hemodialysis and duration since its onset, and plasma levels of parathyrin (PTH).MethodsRetrospective series of 38 patients referred for preoperative parathyroid scintigraphy due to secondary hyperparathyroidism who then underwent parathyroidectomy. Scintigraphy was performed 20 min and then 3 h after injection of 8 MBq/kg of sestamibi (^99mTc) with a previous ingestion of 0.1 MBq/kg iodine-123, 3 h before.ResultNo significant correlation was observed between the number of glands detected on scintigraphy (and confirmed by postoperative histology) and plasma PTH levels (r = ?0.17). A weak positive correlation (r = +0.34) was noted in the group of six non-hemodialysed patients. No significant relationship between this number of detected glands and a clinical parameter was observed.ConclusionIn our experience, these parameters do not permit to select, among patients with secondary hyperparathyroidism and scheduled for parathyroidectomy, those who will better benefit from parathyroid scintigraphy.     

Factores de riesgo cardiovascular en pacientes con hiperparatiroidismo primario asintomático

ObjectivesPatients with primary hyperparathyroidism (PHP), even asymptomatic, have an increased cardiovascular risk. However, data on reversibility or improvement of cardiovascular disorders with surgery are controversial. Our aims were to assess the prevalence of classic cardiovascular risk factors in patients with asymptomatic PHP, to explore their relationship with calcium and PTH levels, and analyze the effect of parathyroidectomy on those cardiovascular risk factors.Patients and methodsA retrospective, observational study of two groups of patients with asymptomatic PHP: 40 patients on observation and 33 patients who underwent surgery. Clinical and biochemical data related to PHP and various cardiovascular risk factors were collected from all patients at baseline and one year after surgery in the operated patients.ResultsA high prevalence of obesity (59.9%), type 2 diabetes mellitus (25%), high blood pressure (47.2%), and dyslipidemia (44.4%) was found in the total sample, with no difference between the study groups. Serum calcium and PTH levels positively correlated with BMI (r = .568, P = .011, and r = .509, P = .026 respectively) in non-operated patients. One year after parathyroidectomy, no improvement occurred in the cardiovascular risk factors considered.ConclusionsOur results confirm the high prevalence of obesity, type 2 diabetes mellitus, high blood pressure, and dyslipidemia in patients with asymptomatic PHP. However, parathyroidectomy did not improve these cardiovascular risk factors     

HRPT2- (CDC73) Related Hereditary Hyperparathyroidism: A Case Series From Western India

Objective: To describe a case series of HRPT2- (CDC73) related hereditary primary hyperparathyroidism (PHPT) from western India.Methods: We present a case series of 4 families (7 patients) with PHPT caused by CDC73 gene mutations.Results: The mean age of presentation of the 4 index cases was 27.25 ± 9.8 years. Two family members were identified through biochemical screening (Cases 1b and 2b), while 1 mutation-positive family member did not manifest any features of PHPT or hyperparathyroidism jaw tumor syndrome (HPT-JT) syndrome (Case 2c). Biochemistry showed increased serum calcium (mean: 13.21 ± 1.24 mg/dL), low serum phosphorus (mean: 1.78 ± 0.44 mg/dL), and high parathyroid hormone (PTH, mean: 936 ± 586.9 pg/mL).All patients had a uniglandular presentation and underwent single adenoma excision initially except Cases 2a and 2b, who underwent subtotal parathyroidectomy at baseline. Two cases experienced PHPT recurrence (Cases 3 and 4), while 1 remained uncured due to parathyroid carcinoma (Case 1a). Other associated syndromic features like ossifying jaw fibromas were present in 2 patients, renal cysts in 3 patients, and uterine involvement in 2 patients. Two families had novel germline CDC73 mutations (Families 1 and 3), while the other 2 had reported mutations. Family 2 had familial isolated PHPT without any other features of HPT-JT syndrome.Conclusion: Our findings reaffirm the need for genetic analysis of patients with PHPT, especially those with younger age of disease onset; recurrent disease; and associated features like polycystic kidneys, endometrial involvement, ossifying jaw tumors, or parathyroid carcinoma.Abbreviations: FIHP = familial isolated hyperparathyroidism HPT-JT = hyperparathyroidism jaw tumor syndrome PHPT = primary hyperparathyroidism PTH = parathyroid hormone ⁹⁹Tc = ⁹⁹Technetium     

Surgeon-Performed Ultrasonography as an Adjunct to Minimally Invasive Radio-Guided Parathyroidectomy in 100 Consecutive Patients with Primary Hyperparathyroidism

ObjectiveTo examine whether surgeon-performed ultrasonography (SPU) in patients with primary hyperparathyroidism and negative preoperative sestamibi scans improves adenoma localization, increases the directed unilateral exploration rate, and reduces operative time and length of hospital stay.MethodsWe retrospectively analyzed 100 consecutive patients with primary hyperparathyroidism encountered between January 1, 2005, and March 31, 2007. Patients underwent preoperative sestamibi scanning and SPU. Minimally invasive radio-guided parathyroidectomy (MIRP) was performed on patients with positive sestamibi scans. In sestamibi scan–negative patients, unilateral exploration was performed with removal of the adenoma, which was submitted for frozen section. Accuracy, operative time, hospital length of stay, mortality, and morbidity were assessed.ResultsOf 100 patients, 79 had positive sestamibi scans and underwent MIRP. Twenty-one had negative sestamibi scans, 18 of whom underwent SPU. Parathyroid adenoma was localized in 17 (94%) of the 18 patients. Operative time and length of hospital stay were not significantly different between sestamibi scan–negative patients who underwent SPU with directed unilateral exploration and sestamibi scan–positive patients who underwent MIRP (operative time: 46 minutes vs 38 minutes, respectively; length of hospital stay: 17.8 hours vs 16.1 hours, respectively). Operative time and length of hospital stay were significantly shorter in sestamibi scan–negative patients who underwent SPU with directed unilateral exploration and in patients who underwent MIRP than in historical controls who underwent 4-gland exploration (P < .01 for both outcomes). No morbidity or mortality was documented.ConclusionSPU localizes 94% of adenomas in sestamibi scan–negative patients, which allows for directed unilateral exploration and results in operative time and length of hospital stay not significantly different from patients undergoing MIRP. (Endocr Pract. 2008;14:28-32)     

Hiperparatiroidismo secundario en el cáncer de próstata avanzado

Background and ObjectiveHigh parathyroid hormone (PTH) concentrations are associated with increased bone resorption and bone matrix degradation. Some studies show elevated PTH concentrations and hypocalcemia in patients with advanced prostate carcinoma, although the pathophysiological significance of these findings is not well defined.Materials and methodsWe performed a retrospective study of 60 patients diagnosed with advanced prostate cancer (44 nonmetastatic and 16 metastatic) treated with androgen deprivation. In all patients, PTH, calcium, phosphorus, 25 (OH) vitamin D and prostate-specific antigen (PSA) were determined. Bone scintigraphy had previously been performed.ResultsIn patients with bone metastases, mean concentrations were as follows: calcium 9.19 mg/dl, phosphorus 3.47 mg/dl, 25 (OH) vitamin D 13.85 ng/ml, PTH 66.8 pg/ml and total PSA 101.27 ng/ml. For those without bone metastases, the results were calcium 9.39 mg/dl, phosphorus 3.38 mg/dl, 25 (OH) vitamin D 20.50 ng/ml, PTH 52.23 pg/ml and total PSA 2.52 ng/ml. PTH levels were significantly higher in patients with prostate cancer and bone metastases than in those without metastases (p=0.03). Vitamin D levels were also significantly lower in this group (p=0.03). There were no differences in other values.ConclusionsThe present study found increased PTH concentrations in patients with advanced prostate cancer. This finding could be useful to predict disease progression.     

Hyperparathyroïdie primaire : confrontation scintigraphie parathyroïdienne TEMP-TDM au MIBI-Tc99m aux données histologiques

BackgroundPrimary Hyperparathyroidism is a common endocrinopathie whose parathyroid scintigraphy is part of its preoperative assessment. Our aim was to compare our results of scintigraphy with single-photon emission tomography coupled with a scanner (SPECT-CT) with the operative data and in particular histological data.MethodsRetrospective study including 46 patients who underwent surgery for hyperparathyroidism and had a positive parathyroid scintigraphy and in whom the definitive operative and histological reports are available.ResultsThe mean age was 56.7 years with a sex ratio of 0.12. The median parathyroid hormone (PTH) was 246 pg./ml with mean serum calcium of 113.5 mg/ml. The sensitivities of cervical ultrasound, planar scintigraphy and SPECT-CT were respectively 50 %, 89.12 % and 95.65 %. A SPECT-CT had a better sensitivity in patients with a nodular thyroid or ectopic or infracentimetric adenoma. Surgical exploration was unilateral in 69.5 % of cases. Intraoperative PTH was reduced by more than 50 % in 95 % of patients. As for the histology, considered the gold standard diagnostic examination, it concluded that a parathyroid adenoma was found in 45 patients. The resected parathyroid parenchyma was normal in a single patient despite the hypertrophic appearance.ConclusionThe main contribution of SPECT-CT is the accurate localization of ectopic hyper functional glands, thus selecting patients for unilateral or minimally invasive cervical surgery and reducing the rate of therapeutic failure. It has also better results than planar scintigraphy in small parathyroid glands and in cases associated to nodular thyroids.     

Intérêt de l’imagerie hybride TEMP/TDM pour la détection de l’ectopie parathyroïdienne. Expérience du service de médecine nucléaire – CHU Mohammed VI,Marrakech

IntroductionHyperparathyroidism due to a parathyroid ectopia is a rare disease; it is the most common cause of persistent or recurrent hyperparathyroidism. Its treatment is exclusively surgical and the results of the surgery benefit from the contribution of preoperative imaging techniques. The aim of this work is to illustrate the interest of the single photon emission computed tomography/computed tomography (SPECT/CT) in the detection and treatment of ectopic parathyroid orientation.Case reportClinical case 1: a 41-year-old patient was followed for persistent primary hyperparathyroidism revealed by brown tumors at the level of the lower extremity of the right femur and tibia. The rate of parathormone was 1987.4 pg/mL. The cervical echography and the scanning were not decisive. The SPECT/CT, performed during a ^99mTc-MIBI scintigraphy and the same for the 2nd clinical case, has showed an area of high uptake projecting behind the left sternoclavicular joint. The diagnosis of ectopic parathyroid localization was retained. Resection and pathologic examination of the surgical specimen revealed parathyroid adenoma tissue. The evolution was marked by a normalization of the rate of parathormone. Clinical case 2: a 71-year-old patient who presents a clinico-biological board of primitive persistent hyperparathyroidism. A first scintigraphy (^99mTc-MIBI) realized in 2010 was negative. The rate of parathormone was 969 ng/L, the rate of calcium was 2.90 mmol/L. Two cervical ultrasound were normal. The SPECT/CT has objectified an area of high uptake in projection at the upper floor of the middle mediastinum. The diagnosis of ectopic parathyroid localization was retained. Surgical resection and histological study revealed a parathyroid adenoma tissue. The evolution was marked by a normalization of the rate of parathormone.DiscussionThe SPECT/CT has an important role in the management of patients with persistent or recurrent hyperparathyroidism. It can usually visualize ectopic parathyroid injury, specify its size and anatomic relationships to optimize surgical management.     

Greater Than Age-Predicted Functional Deficits In Older Patients with Primary Hyperparathyroidism

ObjectiveTo compare the functional capacity of “asymptomatic” patients with primary hyperparathyroidism (PHPT) with normative values of healthy age-matched subjects.MethodsEighteen asymptomatic patients with PHPT met the study inclusion criteria: age > 55 years, serum calcium concentration elevated ≤ 1 mg/dL above normal, inappropriate elevation of parathyroid hormone (PTH) level, and no objective symptoms of PHPT. Functional capacity was assessed by (1) a 6-minute walk test, (2) time to complete 2 sit-to-stand maneuvers, (3) gait velocity, and (4) forward reach. Serum calcium, 25-hydroxyvitamin D, and PTH levels were measured by standard laboratory assays. Functional outcomes of the study patients were compared with age-matched normative values (unpaired t test) and correlated with these biomarkers. Because these patients often have weakness, fatigue, and malaise, we hypothesized that their functional capacity would be compromised relative to that of healthy, age-matched persons.ResultsThe mean age of the patients was 65.6 years, and the mean serum calcium, PTH, and 25-hydroxyvitamin D levels (and standard deviations) were 10.36 ± 0.37 mg/dL, 122.22 ± 39.54 pg/mL, and 44.4 ± 14.27 ng/mL, respectively. Relative to normative values of healthy, agematched subjects, these patients had comparable 6-minute walk distances but required a 37% longer time to complete a repeated sit-to-stand maneuver (P < .05), demonstrated a 52% slower gait speed (P < .001), and had a greater forward reach (P = .05).ConclusionOur findings suggest that older asymptomatic patients with PHPT may have significant functional deficits that can affect their safety and quality of life. Therefore, their functional capacity should be routinely evaluated, and identified deficits should be treated with appropriate interventions. (Endocr Pract. 2012;18: 450-455)     

Impacto asistencial tras la introducción de la ecografía tiroidea en una unidad monográfica de atención al nódulo tiroideo

IntroductionWorldwide incidence of thyroid cancer has increased in recent decades.ObjectiveTo provide evidence of the diagnostic and care efficiency of a monographic thyroid nodule clinic integrating clinical examination, ultrasound examination, and cytology with on site evaluation.Patients and methodsPatients attending the monographic thyroid nodule clinic from January 2004 to June 2010. Two periods may be distinguished based on availability of ultrasound equipment at the time of the visit: a first period (P1: 01/2004-09/2007) where no ultrasound equipment was available at the clinic and FNA by palpation was performed, and a second period (P2: 10/2007-06/2010) where this equipment was available and ultrasound-guided FNA was performed.ResultsA total of 1036 patients [P1: 537 (52%), P2: 499 (48%)] were seen and enrolled.Diagnostic efficiency (P1 vs P2): 143 vs 181 patients were seen annually, p < 0.001; FNA number/nodule: 1.68 vs 1.17, p < 0.001; percent FNAs with inadequate material: 26% vs 5.3%, p < 0.001; mean (SD) nodule size: 23.6 (12.4) vs 21.7 (11.7) mm, p 0.040; proportion of nodules examined less than 10 mm in size: 9.9% vs 13.7%, p 0.030.Care efficiency: mean time (range) from the first visit to surgery indication: 332 (0-2177) vs 108 (0-596) days, p < 0.001; proportion of patients referred for surgery due to suspect cytology/other reasons: 1.06 vs 2.21, p < 0.001; and operated benign neoplasm/pathology: 0.47 vs 0.93, p = 0.002.ConclusionA monographic thyroid nodule clinic integrating clinical examination, ultrasound, and cytology evaluated on site increases diagnostic and care efficiency in patients with thyroid nodules.     

Assay of Free Thyroxine and Free Triiodothyronine in Fine-Needle Aspiration of Thyroid Nodules: a Useful and Low-Cost Assessment

ObjectiveTo evaluate whether analysis of thyroid hormones in fine-needle aspiration (FNA) of thyroid nodules can provide information about the functional status and the nature of the nodules.MethodsWe studied 4 groups of patients: group 1, 17 patients with autonomous hyperfunctioning thyroid nodules; group 2, 52 patients with cold nonfunctioning thyroid nodules; group 3, 12 patients with malignant thyroid nodules; and group 4 (control group), 10 patients with nonthyroid nodular lesions (enlarged parathyroid glands or lymph nodes). The assay of thyroid hormones was performed in FNA after the washing of needles and, with patient consent, also in normal thyroid parenchyma.ResultsThe free thyroxine (FT₄) and free triiodothyronine (FT₃) values were remarkably high in group 1 (mean, 5.5 ± 0.53 ng/dL and 27.6 ± 3.1 pg/mL, respectively; P < 0.05 versus group 2 and group 4, the control group). The levels of FT₄ and FT₃ were very low in group 3 (< 0.2 ng/dL and < 1.0 pg/mL, respectively; P < 0.05 versus group 2). Thyroglobulin values in FNA specimens were much higher than the normal range in human serum, but no significant differences were found between the various groups. The control group had low levels of FT₄ and FT₃ (< 0.2 ng/dL and < 1.0 pg/mL, respectively) in conjunction with low levels of thyroglobulin, whereas parathyroid hormone levels were high in parathyroid nodules.ConclusionThese results show that assay of FT₄ and FT₃ in FNA can yield information about the functional status of thyroid nodules and, indirectly, about the nature of nodules. In this era of sophisticated new molecular markers in FNA cytology, this low-cost diagnostic method can be readily performed in every laboratory. (Endocr Pract. 2004;10:311-316)     

A new, vitamin D-based, multidimensional nomogram for the diagnosis of primary hyperparathyroidism

ObjectiveTo refine the diagnostic criteria for primary hyperparathyroidism (1°HPT) to identify atypical patients, in whom serum calcium, parathyroid hormone (PTH), or both are within the “normal” range.MethodsTotal serum calcium, intact PTH, and 25-hydroxyvitamin D [25(OH)D] levels were measured in patients with 1°HPT and healthy patient groups. Multivariate analysis of healthy patient data first identified factors that significantly affected PTH levels and defined a new PTH reference range with a mathematical model. That nomogram was then validated for prediction of atypical 1°HPT in patients with surgically confirmed disease.ResultsOn multivariate analysis, calcium (P = .0002), 25(OH)D (P < .0001), and age (P = .015) independently affected PTH. With these variables, we created a 4-dimensional nomogram that distinguished normal patients from those with hyperparathyroid states. Mathematically, this nomogram predicts 1°HPT when the measured serum PTH value is higher than PTH calculated by the following formula: PTH (pg/mL) = 120-[6 × calcium (mg/dL)]-[0.52 × 25(OH)D (ng/mL)] + [0.26 × patient age (years)]. When applied to our surgical group of patients, this nomogram successfully identified 100% of patients (238 of 238) with classic 1°HPT, 84% (64 of 76) with normocalcemic 1°HPT, and 54% (20 of 37) with 1°HPT and normal PTH.ConclusionThis study uniquely defines a patientspecific upper limit of normal for PTH based on the readily available variables of serum calcium, 25(OH)D, and patient age. Our nomogram may allow for more rapid definitive diagnosis and treatment of 1°HPT in patients with atypical presentations. (Endocr Pract. 2012;18:124-131)     

Association between family history of malignant neoplasm with colorectal adenomatous polyp in 40s aged relative person

PurposeWe assessed the association between a family history of malignancy and risk of colorectal adenoma among individuals aged 40–49 years.MethodsThe study population consisted of subjects, aged in their 40s, who underwent colonoscopy. Their family histories of cancer were collected with a self-administered questionnaire. A logistic regression model was used to assess the association between a family history of cancer and the risk of colorectal polyp.ResultsIn total, 2275 participants were included in the study. Univariate analysis showed that old age, male sex, current cigarette smoking, BMI > 25 kg/m², and a family history of colorectal cancer (CRC) were risk factors for the development of sporadic colorectal adenomatous polyps in these patients. A multivariate analysis showed that a family history of CRC or kidney cancer was associated with adenoma development. A family history of CRC was also a risk factor for advanced and multiple adenoma.ConclusionsThis study shows that a family history of CRC is a risk factor for advanced and multiple colorectal adenoma in people in their 40s. These results support earlier screening for colorectal neoplasms in individuals with a family history of CRC.     

Serum 25-Hydroxyvitamin D Deficiency; A Risk Factor for Chronic Kidney Disease in Ambulatory Indigent Patients

ObjectiveTo assess whether 25-hydroxyvitamin D (25[OH]D) deficiency is a risk factor for chronic kidney disease (CKD) in ambulatory indigent patients.MethodsData for all serum 25(OH)D concentrations measured during 2010 in our ambulatory nondialysis-dependent patients were analyzed along with CKD-related parameters. Patients were stratified into groups based on 25(OH)D levels of < 10, 10 to 19, 20 to 29, and ≥ 30 ng/mL. CKD was defined by estimated glomerular filtration rate (eGFR; Chronic Kidney Disease-Epidemiology Collaboration [CKD-EPI] equation) and abnormal urine protein to creatinine ratios. CKD-associated parameters included serum parathyroid hormone (PTH), 1,25-dihydroxyvitamin D (1,25[OH]₂D), alkaline phosphatase, albumin, corrected calcium, and total CO₂ levels.ResultsA total of 2,811 patients had 25(OH)D levels measured. Patients with 25(OH)D levels < 10 ng/mL had significantly increased relative risk (RR) of an eGFR < 15 mL/min/1.73 m² (RR, 4.0), an eGFR of 15 to 29 mL/min/1.73 m² (RR, 2.6), urine protein to creatinine ratio > 3.5 g/g (RR, 5.6), and serum PTH > 100 pg/mL (RR, 2.8) compared to patients with a 25(OH)D level ≥ 30 ng/mL. Patients with 25(OH)D levels of 10 to19 ng/mL had significantly increased RR of a urine protein to creatinine ratio > 3.5 g/g (RR,4.8) and serum PTH > 100 pg/mL (RR, 1.5) compared to patients with 25(OH)D levels ≥ 30 ng/mL.Conclusion25(OH)D deficiency (< 10 ng/mL) was associated with reduced eGFR, nephrotic-range proteinuria, and increased PTH levels in our population of ambulatory urban indigent patients. (Endocr Pract. 2014;20:236-243)     

Thyroid-Related Factors that Influence Preoperative Localization of Parathyroid Adenomas

ObjectiveTo evaluate the effect that thyroid-related factors have on the preoperative localization of parathyroid adenomas.MethodsThis retrospective study included adult patients who were referred for further evaluation of primary hyperparathyroidism between December 2005 and October 2009 at a teaching and research hospital in Turkey. High-frequency ultrasonography and sestamibi scintigraphy (MIBI) were performed in all patients. Surgical procedure involved focal or bilateral exploration on the basis of concordant or discordant imaging studies. Selection of patients for minimally invasive parathyroidectomy was made based on the presence or absence of a single parathyroid adenoma detected by both ultrasonography and MIBI scan. Patients with negative or discordant imaging studies and a concomitant thyroid nodule underwent bilateral neck exploration.ResultsTwo hundred and forty-eight patients with primary hyperparathyroidism who underwent parathyroidectomy were included in the study. Parathyroid gland abnormalities were successfully detected preoperatively by ultrasonography in 231 patients and by MIBI scan in 152 patients. When used together, ultrasonography and MIBI scan were unsuccessful in detecting an abnormality in 11 cases. MIBI scan visualized a lesion in 6 cases that remained undiagnosed by ultrasonography. Fifty-six of 85 patients with lesions detected by ultrasonography, but not by MIBI scan, had thyroid nodules. The frequency of thyroid nodules was higher in the 96 patients in whom a MIBI scan could visualize a parathyroid lesion than in the 152 patients in whom MIBI scan was successful (P = .004). No difference was observed regarding ipsilateral thyroid lobe involvement or nodule volume. Parathyroid adenomas were significantly smaller in patients with negative MIBI scans (P < .001).ConclusionOur results suggest that ultrasonography is more sensitive than MIBI scan in the detection of parathyroid adenomas, particularly in the presence of small parathyroid adenomas or other thyroid related-factors. (Endocr Pract. 2012;18:26-33)     

Three large, functioning cystic parathyroid adenomas

ObjectiveTo report a very rare case of 3 large, functioning cystic parathyroid adenomas causing primary hyperparathyroidism.MethodsWe present the history, clinical findings, laboratory test results, radiologic findings, endocrine workup results, intraoperative surgical challenges, and surgical pathology report of the study patient. We review the literature and discuss the importance of intraoperative parathyroid hormone (PTH) measurement in such cases.ResultsA 79-year-old woman presented with primary hyperparathyroidism and elevated levels of calcium and PTH. Localization studies confirmed the presence of a large right upper parathyroid adenoma. On exploration, a very large cystic parathyroid gland was identified at that location. Because intraoperative PTH levels remained elevated, further exploration was pursued, which revealed 2 more large cystic glands on the left side that were resected. This resulted in an adequate but slow PTH drop. The right lower gland appeared normal. On follow-up 4 days and 6 weeks after surgery, the calcium and PTH levels had normalized.ConclusionThis case highlights the aspects of intraoperative PTH use and underscores the need to exclude multigland disease even in the setting of a very large parathyroid cyst with concordant localization studies. (Endocr Pract. 2012;18:e14-e16)     

Low Urine Calcium Excretion in African American Patients with Primary Hyperparathyroidism

ObjectiveTo evaluate the prevalence of low urine calcium excretion in African American patients with primary hyperparathyroidism (PHPT), a common disorder associated with bone and renal complications, and to assess the distinction between PHPT and familial hypocalciuric hypercalcemia (FHH), a rare benign genetic disease.MethodsWe conducted a retrospective study on a cohort of 1,297 patients in whom a 24-hour urine study was performed for measurement of urine calcium and creatinine. PHPT was diagnosed if the serum calcium concentration was ≥ 10.5 mg/dL and intact parathyroid hormone (PTH) was ≥ 40 pg/mL. Patients receiving medications that affect urine calcium or with glomerular filtration rate ≤ 30 mL/min were excluded.ResultsNinety-six patients satisfied the diagnostic criteria for PHPT. The African American (n = 70) and non-African American (n = 26) patients did not differ in their mean age, body mass index, glomerular filtration rate, serum PTH, 25-hydroxyvitamin D levels, and 24-hour urine creatinine values. Median values of urine calcium/creatinine (mg/g) were 122 for African American versus 214 for non-African American patients (P = .006). Thirty-one of 70 African American patients (44%) had a urine calcium/creatinine ratio ≤ 100 mg/g, whereas only 2 of 26 non-African American patients (8%) had this value (P = .001).ConclusionThe prevalence of low urine calcium excretion among African American patients with PHPT is unexpectedly high. A threshold of 100 mg/g urine calcium/ creatinine identified 44% of such patients with PHPT as having FHH in this cohort. Therefore, other clinical criteria and laboratory variables should be used to distinguish PHPT from FHH in African American patients with PTH-dependent hypercalcemia. (Endocr Pract. 2011;17: 867-872)     

Suppressibility of Parathyroid Hormone in Primary Hyperparathyroidism

ObjectiveTo describe an unusual case of pathologically confirmed primary hyperparathyroidism in a patient presenting with severe hypercalcemia and an undetectable parathyroid hormone (PTH) level.MethodsWe present a detailed case report and outline the serial laboratory findings. In addition, the possible causes of low serum PTH levels in the setting of primary hyperparathyroidism are discussed.ResultsA 16-year-old female patient presented with severe epigastric pain, found to be attributable to acute pancreatitis. At hospital admission, her serum calcium concentration was high (14.0 mg/dL); the patient also had a normal serum phosphorus level of 3.6 mg/dL and an undetectable PTH level (< 0.2 pmol/L). An evaluation for non-PTH-mediated causes of hypercalcemia revealed a partially suppressed thyroid-stimulating hormone concentration and a below normal 1,25-dihydroxyvitamin D level, consistent with her suppressed PTH. One week after the patient was dismissed from the hospital, repeated laboratory studies showed a serum calcium value of 11.1 mg/dL, a serum phosphorus level of 2.8 mg/dL, and an elevated PTH concentration of 11.0 pmol/L, consistent with primary hyperparathyroidism. A repeated 1,25-dihy-droxyvitamin D measurement was elevated. A parathyroid scan showed a parathyroid adenoma in the left lower neck area, and she subsequently underwent successful surgical resection of a pathologically confirmed parathyroid adenoma.ConclusionThis case demonstrates that the serum PTH level can be suppressed in patients with primary hyperparathyroidism. Moreover, it emphasizes the need for careful evaluation of the clinical context in which the PTH measurement is determined. Consideration should be given to repeating measurement of PTH and serum calcium levels when the initial laboratory evaluation of hypercalcemia is unclear because dynamic changes in calcium metabolism may occur in the presence of secondary contributing factors. (Endocr Pract. 2007;13:785-789)