Expect the unexpected:Brown tumor of the mandible as the first manifestation of primary hyperparathyroidism

Hyperparathyroidism(HPT)is a condition in which one or more parathyroid glands produce increased levels of parathyroid hormone(PTH),causing disturbances in calcium homeostasis.Most commonly HPT presents with asymptomatic hypercalcemia but the clinical spectrum may include disturbances reflecting the combined effects of increased PTH secretion and hypercalcemia.Brown tumors are rare,benign,tumor-like bone lesions,occurring in 1.5%to 4.5%of patients with HPT,as a complication of an uncontrolled disease pathway,and are nowadays rarely seen in clinical practice.The tumor can appear either as a solitary or multifocal lesion and usually presents as an asymptomatic swelling or a painful exophytic mass.Furthermore,it can cause a pathological fracture or skeletal pain and be radiologically described as a lytic bone lesion.The diagnosis of a brown tumor in HPT is typically confirmed by assessing the levels of serum calcium,phosphorus,and PTH.Although when present,brown tumor is quite pathognomonic for HPT,the histologic finding often suggests a giant cell tumor,while clinical presentation might suggest other more frequent pathologies such as metastatic tumors.Treatment of brown tumors frequently focuses on managing the underlying HPT,which can often lead to regression and resolution of the lesion,without the need for surgical intervention.However,in refractory cases or when dealing with large symptomatic lesions,surgical treatment may be necessary.

¹¹C-Choline PET/CT in the Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a relative common medical problem caused by the inappropriate secretion of parathyroid hormone (PTH) by one or more parathyroid glands. The diagnosis is established by serum calcium and PTH levels and once the diagnosis is established imaging studies help localize the hyperfunctioning adenoma in preparation for curative surgery. Until now, the imaging studies most commonly utilized in PHPT are ultrasonography and 99mTc-Sesta-methoxyisobutylisonitrile (MIBI) parathyroid scintigraphy. However, these studies often fail to localize the adenoma and inappropriately delay patient referral to a potentially curative surgery. We present the case of a 64-year-old female with symptomatic PHPT who had 3 negative 99mTc-Sestamibi Scans over a period of 5 years who eventually had a PET/CT with 11C-Choline that identified a right lower parathyroid adenoma. She underwent a right lower parathyroidectomy and had a successful outcome. We present a review the current imaging techniques used in the management of PHPT including 99mTc-Sesta-MIBI scintigraphy and its limitations and novel use of PET/CT with 11C-Choline and 18F-Choline in this disease and emphasize the fact that, according to current guidelines, failure to localize the adenoma should not delay referral for curative surgery.

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Primary hyperparathyroidism(pHPT)is the third most common endocrine disease.The surgical procedure aims for permanent cure,but recurrence has been reported in 4%-10%of pHPT patients.Preoperative localization imaging is highly valuable.It includes ultrasound,computed tomography(CT),single-photonemission CT,sestamibi scintigraphy and magnetic resonance imaging.The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months.Ongoing hypercalcemia during this period is defined as persistence,and recurrence is defined as hypercalcemia after six months of normocalcemia.Vitamin D is a crucial factor for a good outcome.Intraoperative parathyroid hormone(PTH)monitoring can safely predict the outcomes and should be suggested.PTH≤40 pg/mL or the traditional decrease≥50%from baseline minimizes the likelihood of persistence.Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology.Risk factors for recurrence are cardiac history,obesity,endoscopic approach and low-volume center(at least 31 cases/year).Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/recurrence.A 6-mo calcium>9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up.18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation.With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement,the recurrence rate has dropped to 2.5%-5%.Sixmonth serum calcium≥9.8 mg/dL and parathyroid hormone≥80 pg/mL indicate a risk of recurrence.Negative sestamibi scintigraphy,diabetes and elevated osteocalcin levels are predictors of multiglandular disease,which brings an increased risk of persistence and recurrence.Bilateral neck exploration was considered the gold-standard diagnostic method.Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques.Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence.Long-term follow-up,even up to 10 years,is necessary.

Acute necrotizing pancreatitis as fi rst manifestation of primary hyperparathyroidism

We report the case of a female patient with severe acute necrotizing pancreatitis associated with hypercalcemia as first manifestation of primary hyperparathyroidism caused by a benign parathyroid adenoma.Initially the acute pancreatitis was treated conservatively.The patient subsequently underwent surgical resection of the parathyroid adenoma and surgical clearance of a large infected pancreatic pseudocyst.Although the association of parathyroid adenoma-induced hypercalcemia and acute pancreatitis is a known medical entity,it is very uncommon.The pathophysiology of hypercalcemia-induced acute pancreatitis is therefore not well known,although some mechanisms have been proposed.It is important to treat the provoking factor.Therefore,the cause of hypercalcemia should be identif ied early.Surgical resection of the parathyroid adenoma is the ultimate therapy.

Acute pancreatitis with hypercalcemia caused by primary hyperparathyroidism associated with paraneoplastic syndrome:A case report and review of literature

BACKGROUND Although acute pancreatitis associated with hyperparathyroidism has occasionally been reported,acute pancreatitis with metabolic encephalopathy caused by hyperparathyroidism combined with paraneoplastic syndrome is an extremely rare entity and poorly described in the literature.CASE SUMMARY We present a case of a 56-year-old female with upper abdominal discomfort and intermittent nausea and vomiting for 1 wk,without apparent abdominal pain or bloating,no jaundice and decreased blood pressure at the outset.The patient was ultimately diagnosed with moderately severe acute pancreatitis(according to the revised Atlanta classification of acute pancreatitis)combined with metabolic encephalopathy secondary to hypercalcemia caused by primary hyperparathyroidism associated with paraneoplastic syndrome.After active treatment of acute pancreatitis,massive fluid resuscitation,resection of parathyroid and uterine malignant tumors,neoadjuvant chemotherapy and other treatments,her serum calcium eventually returned to the normal level.The patient was successfully discharged from hospital.CONCLUSION This is the first case of acute pancreatitis caused by primary hyperparathyroidism associated with paraneoplastic syndrome.

Long Term Outcome of Bisphosphonate Therapy in Patients with Primary Hyperparathyroidism

Context: Primary hyperparathyroidism (PHPT) is commonly associated with reduced bone mineral density (BMD) presenting with osteoporosis, increasing the risk of bone fragility fractures in these patients. Bisphosphonates, due to their anti-resorptive action, are known to improve the BMD and reduce the risk of bone fragility fractures. Therefore, bisphosphonates are considered as an alternative to surgical treatment in managing osteoporosis in PHPT patients. Aim: The aim of this observational study was to assess the effect of long term bisphosphonate therapy on BMD, bone fragility fracture and biochemical markers of bone metabolism in patients with PHPT. Methodology: Fifty patients (mean age 74 years) with PHPT who were treated with long term bisphosphonate therapy were studied retrospectively. The mean baseline (before commencing bisphosphonate therapy) BMD T-scores for lumbar spine (L2-L4) and left femoral neck were -2.5 and -2.1, respectively. Fourteen patients had bone fragility fractures before initiation of bisphosphonate therapy. Results: After an average of 5 years of bisphosphonate treatment, there was a significant increase in lumbar BMD T-score (-2.5 to -2.1, p = 0.013) and a non-significant change in left femoral neck BMD T-score (-2.1 to -2.2, p = 0.497). There was no increase in bone fragility fracture rate (p = 0.167). Serum corrected calcium reduced from 2.74 mmol/L to 2.60 mmol/L (p 0.001) and urine calcium to creatinine ratio from 0.70 to 0.55 (p 0.0001), both within the reference range. Conclusions: Our study suggests that long term bisphosphonate therapy improves lumbar BMD and prevents increase in bone fragility fracture rate. Additionally it improves hypercalcaemia in PHPT.

Minimally Invasive Mediastinal Parathyroidectomy: An Effective and Safe Technique in Patients with Ectopic Primary Hyperparathyroidism

Introduction: Primary hyperparathyroidism is a disease commonly caused by a single parathyroid adenoma in 80% - 85% of cases, and is less frequently caused by parathyroid hyperplasia. In approximately 2% of cases, the ectopic parathyroid adenoma is located within the mediastinum. Safely targeted parathyroidectomy is the gold standard procedure for surgical management of primary hyperparathyroidism. We reviewed our surgical experience using video-assisted thoracic surgery and a robotic technique for surgical resection of mediastinal parathyroid adenoma, caused by primary hyperparathyroidism. Materials and Methods: From July 2010 to September 2016, six consecutive patients with symptomatic primary hyperparathyroidism were evaluated with neck ultrasound computed tomography (CT), technetium-99 sestamibi scintigraphy, and selective venous sampling with a measurement of parathyroid hormone levels. Four patients underwent video-assisted thoracic parathyroidectomy and two patients had robotic-assisted parathyroidectomy. Results:? In six patients, there were four women and two men with a mean age of 47.5 years (ranging from 31 - 60 years). The mediastinal parathyroid adenomas were successfully localized by preoperative imaging studies in five patients. Only in one patient, we were unable to localize the parathyroid adenoma. All parathyroid adenomas were successfully resected without any complications. Conclusions: We found that minimally invasive mediastinal parathyroidectomy is promising, safe, and effective in a selected group of patients, as well as providing superior cosmetic results and a short hospital stay.

Xanthogranulomatous Pyelonephritis Associated with Crohn’s Disease and Primary Hyperparathyroidism

We report on a case of unilateral and diffuse xanthogranulomatous pyelonephritis (XGP) associated with Crohn’s disease and primary hyperparathyroidism (HPT). The patient had undiagnosed primary HPT for at least a year prior to presentation. The co-existence of Crohn’s disease and primary HPT caused calcium oxalate stone likely by the known mechanism of hypercalcemia and hyperoxaluria respectively. The patient developed XGP, a rare disease, as a result of infected calcium oxalate stone which was treated with antibiotics and unilateral nephrectomy. To the best of our knowledge, this is the first case of XGP associated with Crohn’s disease and primary HPT.

Brown Tumor of the Maxilla Revealing Primary Hyperparathyroidism

Brown tumor or localized form of osteitis fibrosa cystic is a focal lesion complicating hyperpara-thyroidism. It’s rarely revelatory of the clinical feature and corresponds to a mass with partly cystic and partly solid areas. A 65-year-old man, followed up for hypertension, complained of a progressive swelling in the left paranasal part of the face lasting for 3 months. Physical examination revealed a left paranasal swelling of 4 cm diameter, with a healthy looking skin. CT facial bones found a round formation of 2 cm involving the left maxilla. He received tumor resection by vestibular pathway. Histological examination showed many giant cells. We then discussed the brown tumor diagnosis. The PTH dosage was high: 645 pg/mL (normal: 15 - 68 pg/mL). The serum calcium was in the superior normal limit (100 mg/dL). Cervical ultrasound revealed a bottom left parathyroid nodule. A lower left parathyroidectomy was performed. Histological results confirmed parathyroid adenoma. Monitoring was marked by a marked decrease of the PTH serum level then a return to normal values, a normocalcemia and no recurrence of the maxillary tumor with Recoil of 14 months. Brown tumor of the maxilla is rare and should be considered even in absence of hypercalcemia.

Diagnostic Performance and Inter-Observer Agreement of 4-Dimensional Computed Tomography Parathyroid Scans in Patients with Primary and Secondary Hyperparathyroidism

Background: 4D-CT has been used to localize the parathyroid adenomas and hyperplasia since 2006 as a second line study after TC-99 m MIBI and ultrasonography. However, multiple studies have shown that 4D-CT is a robust imaging method with high diagnostic accuracy, becoming increasingly popular among surgeons and radiologists. Purpose: To assess the diagnostic performance of 4D-CT scans to identify the pathologic gland(s), using pathology and intraoperative findings as gold standards. Methods: We analyzed patients with primary and secondary hyperparathyroidism who had intraoperative reports, pathology, parathyroid hormone levels, and preoperative 4D-CT. Histology, surgical findings, and decreased parathyroid hormone levels were used as gold standards. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and 95% confidence interval were calculated. Fleiss’ kappa was used to assess the inter-observer agreement. Results: Sixty-seven patients were included. Sixty-two patients had a single adenoma, and five patients had a multiple gland disease (adenomas or hyperplasia). A total of 72 glands were proven to have parathyroid adenomas or hyperplasia. The sensitivity, specificity, PPV, NPV and accuracy are 85%, 97%, 96%, 87% and 91% for lateralization and 76%, 96%, 85%, 92% and 90% for quadrant localization, respectively in single-gland disease. The sensitivity, specificity, PPV, NPV and accuracy are 88%, 100%, 100%, 50% and 90% for lateralization and 71%, 100%, 100%, 60% and 80% for quadrant localization respectively in multiple-gland disease. Fleiss’ kappa value is 5.6 (moderate inter-observer agreement). Conclusion: 4D-CT is a robust method in the localization of hyperfunctioning parathyroid glands with high accuracy and at least moderate inter-observer agreement.

Diagnostic dilemma: metastatic bone malignancy or primary hyperparathyroidism with brown tumor

Multiple osteolytic lesions are usually associated with metastatic involvement of the bone. However metabolic bone diseases should also take their place in differential diagnosis. Here, we describe a primary hyperparathyroidism case with full-blown osteolytic lesions wich was diagnosed at first sight with having metastatic bone involvement. PET CT scan and laboratory results excluded a metastatic bone malignancy. Elevated serum calcium of 13.16 mg/dl, decreased serum phoshorus of 1.4 mg/dl and high intact-PTH level of 1054.7 pg/ml pointed out primary hyperparathyroidism. Sonographic examination revealed two adenomas of 2.9 × 3.3 mmand 3.3 ×2.7 mmin the left superior and right inferior parathyroid glands, respectively. Scintigraphy confirmed the presence of adenoma on the left.

The Role of Preoperative Ultrasound and Sestamibi Scintigraphy in the Surgical Management of Primary Hyperparathyroidism: A Review of Literature

Background: Primary hyperparathyroidism (pHPT) is one of the most common endocrine diseases and the most common cause of hypercalcemia. Since routine laboratory testing, the prevalence of the disease has increased from 0.1% to 0.4% worldwide. The only curative treatment is parathyroidectomy. Nowadays, preoperative localization studies have become standard before surgical treatment, and the first stage imaging methods are cervical ultrasonography (US) and/or Sestamibi scintigraphy. Objectives: To describe the accuracy of US and Sestamibi for detection of hyperfunctioning parathyroid adenomas preoperatively in patients with confirmed pHPT from our medical institution. Results: This is a retrospective study from a prospectively kept database that included thirty-one patients with the confirmed diagnosis of pHPT clinically and biochemically. The average age was 57.8 years old. Preoperative US and surgery findings were compared with a sensitivity of 51%. Preoperative Sestamibi and surgery findings were compared resulting in a sensitivity of 71%. Both imaging methods combined, resulted in a sensitivity of 80%. Conclusion: In patients with pHPT, Sestamibi is an effective method for localizing parathyroid pathology preoperatively, but the false negative rate can be high. US tends to have a wider range explained by the operator-dependent factor. The combination of US and Sestamibi reduces the rate of false negatives, as reported in international literature. It is important to mention that these studies cannot be used as a confirmatory test for this disease. It should only be used as an adjunct to help plan the operation.

Additional Imaging Following a Negative Sestamibi Scan in Primary Hyperparathyroidism

Background: The objective of this study was to assess the additional yield of US and CT following a “negative” initial MIBI-scintigraphy (MIBI) in patients with primary hyperparathyroidism. Methods: Prospective data were collected regarding 100 consecutive patients, preferentially undergoing a minimally invasive parathyroidectomy (MIP). MIBI was the initial imaging study for localizing a solitary adenoma, followed by US and CT (US/CT) in “MIBI-negative”-patients. Results: Surgery led to normocalcemia in 98 patients (98%) after one operation. Overall 97 patients had solitary parathyroid disease while three patients had multiglandular disease. The sensitivity of imaging increased from 74% for MIBI alone to 92% following subsequent US/CT in “MIBI-negative”-patients. The positive predictive value of a “positive” MIBI was 96% and 76% of a positive US/CT following negative MIBI. The proportion of patients who underwent successful MIP increased from 60 to 72%. Conclusions: MIBI and the combination of US and CT are complementary imaging studies. Additional localization studies after a negative sestamibi scan enhances the number of patients with primary hyperparathyroidism profiting from a minimally invasive approach.

Parathyroid and bone imaging in primary hyperparathyroidism

Skeletal derangements occur quite often in patient with primary hyperparathyroidism (PHPT). We investigated parathyroid and bone imagings in 59 cases of pathologically proven PHPT. Forty-nine cases were pathologically proven parathyroid adenomas; 8 presented hyperplasia and the other 2 were adenocarcinomas. Parathyroid imaging (early phase imaging, EPI) was conducted at 30 min after injecting 740～925MBq 99mTc-MIBI and 2～3h later (delayed phase imaging, DPI) separately. The following thyroid imagings were performed at the same posture 10 min after intravenous injection of 74～111MBq 99mTcO4-. The 99mTc- MIBI subtraction imaging data were obtained by subtracting thyroid imaging from that of DPI. Among 49 cases of proven hyperparathyroid adenoma 45 yielded positive imagings. Eight cases with hyperplasia gave negative results. The results were positive in 2 cases of parathyroid adenocarcinoma. Results of 99mTc-MDP/bone imaging: 35 cases of hyperparathyroid adenocarcinoma (disease duration 1-6 months) showed normal bone images, while 14 cases showed superscan images, course being 4-12 months. Bone imaging for 2 cases of adenocarcinoma showed multiple, radioactive aggregated foci (brown tumor imaging); course lasting 10-24 months. The results of bone imaging in 8 cases of hyperplasia/ hyperparathyroidism were normal. It was concluded that diagnostic accuracy for parathyroid was 79.6% and for parathyroid adenoma was 91.8%, and the technique has no diagnostic value for hyperplasia. The 99mTc-MDP / bone imaging results for PHPT can be classified into three categories, i.e. normal, superscan and brown tumor. The imaging results correlated well with the different categories and degrees of bone damage, the duration of clinical course and the pathological types. Therefore, it's important to use bone imaging data in association with therapy to reflect the stage and progress of PHPT.

Preoperative localization and minimally invasive management of primary hyperparathyroidism concomitant with thyroid disease

The coexistence of thyroid diseases with primary hyperparathyroidism (PHPT) can present a challenge in the clinical diagnosis and management for these patients. This study aims to determine the frequency of coexisting thyroid gland lesions in a consecutive series patients with PHPT, and to analyze the clinical features, diagnosis and treatment of these patients. Twenty-two cases of a total of 52 PHPT patients who had synchronous thyroid and parathyroid pathology were surgically managed in this study. Thirteen patients had ipsilateral thyroid nodules, and 9 patients had thyroid nodules in contralateral or bilateral side. Seven patients underwent direct parathyroidectomy and hemithyroidectomy via a mini-incision (about 3 cm), while other 15 procedures were converted to Kocher incision. Seventeen nodular goiter (32.7%), 2 thyroiditis (3.8%), 2 thyroid adenoma (3.8%) and 1 thyroid carcinoma (1.9%) coexisting with parathyroid adenoma were pathologically diagnosed. The sensitivity of preoperative ultra-sonography (US) and methoxy-isobutyl-isonitrile (MIBI) scintigraphy for parathyroid lesions was 63.6% and 85.7%; and the overall positive predictive values for MIBI and US were 100% and 95.5% respectively. A high incidence of thyroid diseases that coexisted with PHPT in literatures was briefly reviewed. Our study illustrated the need for clinical awareness of concomitant PHPT and thyroid disease. A combination of US, computed tomography (CT) and MIBI scintigraphy would be recommended for preoperative localization of enlarged parathyroid adenoma and for evaluation of thyroid lesions. Synchronous treatment of asso-ciated thyroid abnormalities is desirable, and open minimally invasive surgical approach with additional resection of isolated ipsilateral thyroid nodules is possible in some of these patients.

Three-dimensional choroidal vascularity index and choroidal thickness in fellow eyes of acute and chronic primary angle-closure using swept-source optical coherence tomography

AIM:To compare the three-dimensional choroidal vascularity index(CVI)and choroidal thickness between fellow eyes of acute primary angle-closure(F-APAC)and chronic primary angle-closure glaucoma(F-CPACG)and the eyes of normal controls.METHODS:This study included 37 patients with unilateral APAC,37 with asymmetric CPACG without prior treatment,and 36 healthy participants.Using swept-source optical coherence tomography(SS-OCT),the macular and peripapillary choroidal thickness and three-dimensional CVI were measured and compared globally and sectorally.Pearson’s correlation analysis and multivariate regression models were used to evaluate choroidal thickness or CVI with related factors.RESULTS:The mean subfoveal CVIs were 0.35±0.10,0.33±0.09,and 0.29±0.04,and the mean subfoveal choroidal thickness were 315.62±52.92,306.22±59.29,and 262.69±45.55μm in the F-APAC,F-CPACG,and normal groups,respectively.All macular sectors showed significantly higher CVIs and choroidal thickness in the F-APAC and F-CPACG eyes than in the normal eyes(P<0.05),while there were no significant differences between the F-APAC and F-CPACG eyes.In the peripapillary region,the mean overall CVIs were 0.21±0.08,0.20±0.08,and 0.19±0.05,and the mean overall choroidal thickness were 180.45±54.18,174.82±50.67,and 176.18±37.94μm in the F-APAC,F-CPACG,and normal groups,respectively.There were no significant differences between any of the two groups in all peripapillary sectors.Younger age,shorter axial length,and the F-APAC or F-CPACG diagnosis were significantly associated with higher subfoveal CVI and thicker subfoveal choroidal thickness(P<0.05).CONCLUSION:The fellow eyes of unilateral APAC or asymmetric CPACG have higher macular CVI and choroidal thickness than those of the normal controls.Neither CVI nor choroidal thickness can distinguish between eyes predisposed to APAC or CPACG.A thicker choroid with a higher vascular volume may play a role in the pathogenesis of primary angle-closure glaucoma.

ROLE OF ^(99)Tc^m-SESTAMIBI DUAL-PHASE PARATHYROID SCINTIGRAPHY IN PREOPERATIVE LOCALIZATION IN PATIENTS WITH PRIMARY HYPERPARATHYROIDISM

Objective To evaluate the application of 99Tcm-sestamibi dual-phase parathyroid scintigraphy in the preoperative localization in patients with primary hyperparathyroidism and to compare the diagnostic efficacy of various imaging modalities. Methods Ninety-two consecutive patients, diagnosed as hyperparathyroidism and presented with hypercalcaemia as the predominant symptom, were included. All the patients underwent dual-phase parathyroid scintigraphy using 99Tcm-sestamibi and parathyroid ultrasound scan. Among them, 48 patients underwent parathyroid computed tomography (CT). All patients were referred for parathyroidectomy. Results 99Tcm-sestamibi dual-phase parathyroid scintigraphy revealed the diagnostic sensitivity of 76.5%, 80%, 75% and 33.3% for the subgroup of single adenomas, multiple adenomas, ectopic parathyroid and parathyroid hyperplasia respectively. The specificity was 100% for all leisons. 99Tcm-sestamibi dual-phase parathyroid scintigraphy was proved to be superior to the other imaging modalities (ultrasound and CT) in terms of the preoperative diagnostic accuracy. The lesion weight was found to be an underlying factor leading to the false negative result. Conclusion 99Tcm-sestamibi dual-phase parathyroid scintigraphy was found to have higher diagnostic accuracy in comparison with other imaging modalities and is recommended preoperatively in order to reduce the sugery time and unnecessary neck exploration.

Primary Hyperparathyroidism Revealed by Impaired Renal Function with Persistent Elevation of Parathormon (PTH) and Normal Calcemia after Surgical Removal of the Parathyroid Adenoma

Introduction: The curative management of primary hyperparathyroidism is based on surgery. We report the case of a patient presenting with elevated parathormone despite surgical removal of the parathyroid adenoma. Observation: A 48-year-old patient presented for more than 6 months with significant weight loss, polyuria with polydipsia and impaired renal function. The assessment carried out revealed hypercalcaemia at 155 mg/L with hypophastetaemia at 24 mg/L and an elevation of the parathyroid hormone at 218.9 pg/ml. Cervical ultrasound showed a mass at the expense of the lower left parathyroid gland. These results made it possible to conclude primary hyperparathyroidism by parathyroid adenoma which was supported surgically. The postoperative biological assessment revealed a normocalcemia at 85 mg/L associated with an increase in parathormone (PTH) at 271.9 pg/ml. In front of the normalization of calcemia in the subsequent controls and the amendment of all the signs, monitoring was carried out. 9 months after surgery, spontaneous normalization of PTH was observed at 38.4 pg/ml with normal serum calcium at 90 mg/l. Discussion: Primary hyperparathyroidism can be revealed by other manifestations. Post-operative follow-up is generally simple with normalization of PTH and serum calcium. However, there may persist an elevation of PTH with normal self-limiting calcemia.

Secondary Hyperparathyroidism in Dialysis Patients: Short- and Long-Term Outcomes of Conservative Parathyroidectomy

Secondary hyperparathyroidism (HPT) is frequent in dialysis patients. Parathyroidectomy (PTX) is indicated for patients who failed medical therapy. We reviewed the data from 184 dialysis patients who underwent PTX between January 2015 and January 2023. We aimed to evaluate the short and long term outcomes of PTX in dialysis patients, comparing the conservative 3/4 versus 7/8 techniques in this population.166 dialysis patients with secondary HPT were included. A conservative subtotal PTX (sPTX) 7/8 was performed in 72% of patients and sPTX 3/4 in 28% of them. Severe postoperative hypocalcaemiaocurred in 45 patients (27%). Hypocalcaemia was significantly more frequent in the sPTX 7/8 group (p = 0.012). One case of persistent HPT (0.6%) and 20 cases of recurrence (12%) were diagnosed. Recurrence was more frequent in the sPTX 3/4 group (15%). No deaths were reported during the perioperative period.

Clinical analysis of multiple primary gastrointestinal malignant tumors:A 10-year case review of a single-center

BACKGROUND Multiple primary malignant tumors(MPMTs)was first described by Billroth as early as 1889,with the first report published by Warren and Gates in 1932.Since then,numerous cases have been reported.A literature review of 1104269 patients with cancer revealed that the incidence of MPMTs ranged from 0.73 to 11.7%.In recent years,however,there has been a significant upward trend in the incidence of this phenomenon,which may be associated with many different factors,including the advancement of modern diagnostic procedures facilitating the examination and diagnosis of more MPMTs,increased exposure to chemotherapy and radiotherapy that exacerbate the risk of new malignant tumors in patients with cancer,and prolonged survival of patients with cancer allowing sufficient time for the development of new primary cancers.AIM To analyze the incidence,clinical features,treatment factors,prevalence,and prognosis of patients with MPMTs in the gastrointestinal tract treated in a single center.Additionally,we analyzed the different tumor combinations,time interval between the occurrence of tumors,and staging.METHODS This retrospective cohort study analyzed 8059 patients with pathologically confirmed gastrointestinal malignant tumors treated at the Gansu Province Hospital in Lanzhou,Gansu,China between June 2011 and June 2020.Of these,85 patients had MPMTs.The clinical features,treatment factors,prevalence,and prognosis of this latter cohort were analyzed.RESULTS The incidence of MPMTs in patients with gastrointestinal malignant tumors was 1.05%(85/8059),including 83 double primary malignant tumors and two triple primary malignant tumors of which 57(67.06%)were synchronous MPMTs(SMPMTs)and 28(32.94%)were metachronous MPMTs(MMPMTs).The most frequent associations were found between the rectum colon cancers within the SMPMT category and the gastric-colon cancers within the MMPMT category.For the MMPMTs,the median interval was 53 months.The overall 1-,3-and 5-year survival rates from diagnosis of the first primary cancer were 91.36%,65.41%,and 45.97%,respectively;those from diagnosis of the second primary cancer were 67.90%,29.90%,and 17.37%,respectively.CONCLUSION MPMTs in the gastrointestinal tract have a high incidence and poor prognosis.Thus,it is necessary to perform both gastroscopy and colonoscopy in patients with gastrointestinal tumors.Multidisciplinary comprehensive diagnosis and treatment may improve the diagnosis rate and treatment efficiency of MPMTs.