Planned parathyroidectomy: the new standard in hypercalcemic crisis

ABSTRACT Objective: The study sought to determine the clinical features of hyperparathyroid-induced hypercalcemic crisis (HIHC) along with treatment options and outcomes. Subjects and methods: This is a retrospective analysis of our historical cohort of patients with primary hyperparathyroidism (PHPT). Patients were divided in groups according to their calcium levels and clinical presentation. HIHC (group 1) was assumed when patients had high calcium levels and needed emergency hospitalization. Group 2 was composed of patients with calcium levels above 16 mg/dL or patients who needed hospitalization for classical PHPT symptoms. Group 3 was composed of clinically stable patients with calcium levels between 14 and 16 mg/dL, who were electively treated. Results: Twenty-nine patients had calcium levels above 14 mg/dL. HIHC group had seven patients, and initial clinical measures had good response in two patients, moderate response in one patient, and poor response in four patients. All poor responders underwent immediate surgery, and one of them died due to HIHC complications. Group 2 had nine patients, and all were successfully treated during hospitalization. Group 3 had 13 patients, and all had a successful elective surgery. Conclusion: HIHC is a life-threatening condition that requires fast clinical intervention. Surgery is the only definitive treatment and should be planned for all patients. Poor response to initial clinical measures should direct treatment toward surgery to avoid disease progression and clinical deterioration.

Sestamibi scan in renal parathyroidectomy: a worthwhile preoperative exam? / Cintilografia com sestamibi na paratireoidectomia renal: um exame pré‐operatório que vale a pena?

Abstract Introduction Surgical treatment of hyperparathyroidism related to chronic kidney disease is a real challenge for Brazilian public health care. High cost medications and long waiting lines to perform preoperative exams, especially technetium Tc 99m Sestamibi (MIBI) are some of the reasons. Despite the reality that the aid of localization exams are questionable in this scenario, doctors are too apprehensive in performing surgery without it. Objective The study aimed at evaluating the efficacy of surgery for renal hyperparathyroidism without preoperative MIBI. Methods A total of 114 patients were surgically treated. Total parathyroidectomy with autotransplantation and subtotal parathyroidectomy were carried out without preoperative MIBI. Results and conclusion Among the 114 patients undergoing surgery, 37 had secondary hyperparathyroidism in dialysis replacement, and 77 patients had post-renal transplant persistent disease. We were successful in 107 cases with only 7 failures (93.8% of success rate). Among these failures, only one parathyroid gland was not found in 4 cases, 2 parathyroid glands were not found in 2 cases and in 1 patient the 4 glands were found but this patient remained hypercalcemic and a postoperative diagnosis of supernumerary parathyroid gland was made. Surgery for treatment of renal hyperparathyroidism proved to be an effective (93.8%) and reproductible procedure, even without MIBI.

Resumo Introdução O tratamento cirúrgico do hiperparatireoidismo relacionado à doença renal crônica é um verdadeiro desafio para a saúde pública brasileira. Medicamentos de alto custo e longas filas de espera para exames pré‐operatórios, principalmente a cintilografia com tecnécio Tc‐99m Sestamibi, MIBI, são alguns dos motivos. Apesar da contribuição de exames de localização ser questionável nesse cenário, os médicos ficam muito apreensivos por fazer uma cirurgia sem ele. Objetivo Avaliar a eficácia da cirurgia para hiperparatireoidismo renal sem o MIBI pré‐operatório. Método Foram tratados cirurgicamente 114 pacientes. A paratireoidectomia total com autotransplante e a paratireoidectomia subtotal foram feitas sem MIBI pré‐operatório. Resultados e conclusão Entre os 114 pacientes submetidos à cirurgia, 37 apresentavam hiperparatireoidismo secundário em reposição dialítica e 77 doença persistente pós‐transplante renal. Tivemos sucesso em 107 casos, com apenas 7 falhas (93,8% de taxa de sucesso). Entre essas falhas, uma glândula paratireoide não foi encontrada em 4 casos, 2 glândulas paratireoides não foram encontradas em 2 casos e em um paciente as 4 glândulas foram encontradas, mas ele permaneceu hipercalcêmico com diagnóstico pós‐operatório de glândula paratireoide supranumerária. A cirurgia para tratamento do hiperparatireoidismo renal mostrou‐se um procedimento eficaz (93,8%) e reprodutível mesmo sem MIBI.

Surgery for primary hyperparathyroidism

ABSTRACT Primary hyperparathyroidism (PHPT) is a hypercalcemic disorder that occurs when one or more parathyroid glands produces excessive parathyroid hormone (PTH). PHPT is typically treated with surgery, and it remains the only definitive therapy, whose techniques have evolved over previous decades. Advances in preoperative localization exams and the intraoperative PTH monitoring have become the cornerstones of recent parathyroidectomy techniques, as minimally invasive techniques are appropriate for most patients. Nevertheless, these techniques, are not suitable for PHPT patients who are at risk for multiglandular disease, especially in those who present with familial forms of PHPT that require bilateral neck exploration. This manuscript also explores other conditions that warrant special consideration during surgical treatment for PHPT: normocalcemic primary hyperparathyroidism, pregnancy, reoperation for persistent or recurrent PHPT, parathyroid carcinoma, and familial and genetic forms of hyperparathyroidism.

Prediction of bone mass changes after successful parathyroidectomy using biochemical markers of bone metabolism in primary hyperparathyroidism: is it clinically useful?

ABSTRACT Objective To measure type 1 serum amino-terminal propeptide procollagen (P1NP) and type 1 cross-linked C-terminal telopeptide collagen (CTX) before parathyroidectomy (PTX) in PHPT patients, correlating these measurements with bone mineral density (BMD) changes. Subjects and methods 31 primary hyperparathyroidism (HPTP) were followed from diagnosis up to 12-18 months after surgery. Serum levels of calcium, parathyroid hormone (PTH) vitamin D, CTX, P1NP, and BMD were measured before and 1 year after surgery. Results One year after PTX, the mean BMD increased by 8.6%, 5.5%, 5.5%, and 2.2% in the lumbar spine, femoral neck (FN), total hip (TH), and distal third of the nondominant radius (R33%), respectively. There was a significant correlation between BMD change 1 year after the PTX and CTX (L1-L4: r = 0.614, p < 0.0003; FN: r = 0.497, p < 0.0051; TH: r = 0.595, p < 0.0005; R33%: r = 0.364, p < 0.043) and P1NP (L1-L4: r = 0,687, p < 0,0001; FN: r = 0,533, p < 0,0024; TH: r = 0,642, p < 0,0001; R33%: r = 0,467, p < 0,0079) preoperative levels. The increase in 25(OH)D levels has no correlation with BMD increase (r = -0.135; p = 0.4816). On linear regression, a minimum preoperative CTX value of 0.331 ng/mL or P1NP of 37.9 ng/mL was associated with a minimum 4% increase in L1-L4 BMD. In TH, minimum preoperative values of 0.684 ng/mL for CTX and 76.0 ng/mL for P1NP were associated with a ≥ 4% increase in BMD. Conclusion PHPT patients presented a significant correlation between preoperative levels of turnover markers and BMD improvement 1 year after PTX.

Initial surgical results of 500 Parathyroidectomies for Hyperparathyroidism related to chronic kidney disease - mineral and bone disorder / Resultados cirúrgicos iniciais de 500 Paratireoidectomias por Hiperparatireoidismo relacionado a distúrbio mineral e ósseo da doença renal crônica

ABSTRACT Introduction: Surgical treatment of hyperparathyroidism related to chronic kidney disease is a challenging procedure even for experienced parathyroid surgeons. Over the years, adjuvant techniques have been developed to assist the medical team to improve surgical outcomes. However, medical staff in poor countries have less access to these techniques and the effectiveness of surgery in this context is unclear. Objective: verify the effectiveness of surgery for treatment of hyperparathyroidism related to chronic kidney disease without adjuvant techniques. Methods: Over a 5-years period, patients with hyperparathyroidism that had clinical therapeutic failure were evaluated for surgical treatment. Total parathyroidectomy with autograft or subtotal resection were the selected procedures. Surgeries were performed in a tertiary hospital in Brazil without the assistance of some of the adjuvant techniques that are usually applied, such as frozen section, nerve monitoring, and gamma probe. Intraoperative PTH and localization pre-operative exams were applied, but with huge restrictions. Results: A total of 518 patients with hyperparathyroidism (128 secondary and 390 tertiary) were surgically treated. Total parathyroidectomy were performed in 81.5%, subtotal in 12.4%, and 61% of patients had a surgical failure. Of all failures, only 1.4% needed a second surgery totaling 98.6% of successful initial surgical treatment. Neck hematoma and unilateral focal fold paralysis occurred in 1.9% and 1.5%, respectively. Conclusion: parathyroidectomy is a safe and reproducible surgical procedure even in the absence of adjuvant techniques.

RESUMO Introdução: O tratamento cirúrgico do hiperparatireoidismo relacionado à doença renal crônica é um procedimento desafiador mesmo para cirurgiões de paratireoide experientes. Ao longo dos anos, técnicas adjuvantes foram desenvolvidas para ajudar a equipe clínica a aprimorar os desfechos cirúrgicos. Contudo, as equipes clínicas de países mais pobres têm menor acesso a tais técnicas, o que faz com que a eficácia da cirurgia nesses contextos não seja tão evidente. Objetivo: Verificar a eficácia da cirurgia para tratamento do hiperparatireoidismo relacionado à doença renal crônica, sem técnicas adjuvantes. Métodos: Ao longo de período de cinco anos, pacientes com hiperparatireoidismo cujo tratamento clínico não resultou em melhora foram avaliados para resolução cirúrgica. Os procedimentos selecionados foram paratireoidectomia total com enxerto autólogo ou ressecção subtotal. As cirurgias foram realizadas em um hospital terciário no Brasil sem o auxílio de algumas das técnicas adjuvantes geralmente aplicadas, como exame de congelação, monitorização neurofisiológica e sonda gama. Exames intraoperatórios de PTH e pré-operatório de localização foram realizados, mas com grandes restrições. Resultados: Um total de 518 pacientes com hiperparatireoidismo (128 secundários e 390 terciários) foram tratados cirurgicamente. Paratireoidectomia total foi realizada em 81,5% e subtotal em 12,4% dos casos; 61% dos pacientes apresentaram falha cirúrgica. De todas as falhas, apenas 1,4% necessitaram de uma segunda cirurgia, totalizando 98,6% de sucesso no tratamento cirúrgico inicial. Hematoma cervical e paralisia unilateral de prega vocal ocorreram em 1,9% e 1,5% dos pacientes, respectivamente. Conclusão: A paratireoidectomia é um procedimento cirúrgico seguro e reprodutível, mesmo na ausência de técnicas adjuvantes.

Diagnosis and treatment of hypoparathyroidism: a position statement from the Brazilian Society of Endocrinology and Metabolism

ABSTRACT Objective To present an update on the diagnosis and treatment of hypoparathyroidism based on the most recent scientific evidence. Materials and methods The Department of Bone and Mineral Metabolism of the Sociedade Brasileira de Endocrinologia e Metabologia (SBEM; Brazilian Society of Endocrinology and Metabolism) was invited to prepare a document following the rules set by the Guidelines Program of the Associação Médica Brasileira (AMB; Brazilian Medical Association). Relevant papers were retrieved from the databases MEDLINE/PubMed, LILACS, and SciELO, and the evidence derived from each article was classified into recommendation levels according to scientific strength and study type. Conclusion An update on the recent scientific literature addressing hypoparathyroidism is presented to serve as a basis for the diagnosis and treatment of this condition in Brazil.

Responsividade paratireoideana à hipocalcemia após paratireoidectomia total com autoimplante em portadores de hiperparatireoidismo associado à doença renal crônica / Parathyroid responsiveness during hypocalcemia after total parathyroidectomy and autotransplantation in patients with renal hyperparathyroidism

Resumo Introdução: O hiperparatireoidismo é uma complicação frequente da doença renal crônica (DRC). A paratireoidectomia (PTX) total com autotransplante (AT) de tecido paratireoideano é uma opção terapêutica para os indivíduos que não respondem ao manejo clínico. Objetivo: Avaliar a resposta do tecido paratireoideano enxertado durante hipocalcemia induzida em pacientes portadores de DRC submetidos à PTX total com AT. Métodos: Dezoito pacientes portadores de hiperparatiroidismo associado à DRC foram submetidos à PTX total com AT de tecido paratireoideano selecionado por estereomicroscopia entre Abril e Outubro de 2008 em nosso serviço. Onze indivíduos (oito com transplante renal funcionante, 2 em diálise peritoneal e 1 em hemodiálise) apresentavam boa condição clínica e foram elegíveis para o teste. Induziu-se hipocalcemia por infusão de bicarbonato de sódio em 5 controles normais e nos pacientes 6-12 meses após a PTX. Resultados: A hipocalcemia determinou um aumento importante dos níveis de PTH intacto (iPTH) no grupo controle 4 minutos após a infusão de bicarbonato. Nos pacientes, houve uma redução significativa do cálcio ionizado [de 1,17 ± 0,12 para 1,09 ± 0,11 (media ± EP) mmol/L] no 4º minuto (p < 0,001) ilustrando o nadir do teste. No 10º minuto não houve elevação do cálcio ionizado comparado ao 4º minuto (p = 0,451). Os níveis de iPTH foram de 34,8 ± 18,6 para 34,1 ± 18,8 pg/mL (valor basal semelhante ao 4º minuto p = 0,087) e se mantiveram no 10º minuto (33,3 ± 19,6 pg/mL p = 0,693). Conclusão: Em pacientes portadores de DRC testados 6-12 meses depois da cirurgia, o enxerto de tecido paratireoideano revelou incapacidade de resposta à hipocalcemia induzida por bicarbonato sem mudança dos níveis de iPTH.

Abstract Introduction: Hyperparathyroidism is a frequent complication of chronic kidney disease (CKD). Total parathyroidectomy (PTX) with parathyroid tissue autotransplantation (AT) is a treatment option in those individuals that do not respond to clinical management. Objective: To evaluate grafted parathyroid tissue response during induced hypocalcemia among CKD patients who underwent total PTX with AT. Methods: Eighteen patients with renal hyperparathyroidism were submitted to total PTX with parathyroid AT selected by stereomicroscopy between April and October 2008. Eleven (eight with successful kidney transplantation, 2 in peritoneal dialysis and 1 in hemodialysis) were clinically stable and eligible for testing. Hypocalcemia was induced using sodium bicarbonate infusion in 5 healthy controls and in patients 6-12 months after surgery. Results: Among controls, hypocalcemia elicited a major rise in intact PTH (iPTH) levels 4 minutes after bicarbonate infusion. In patients, a significant decrease in ionized calcium concentration was observed [from 1.17 ± 0.12 to 1.09 ± 0.11 mean (± SE) mmol/L] in the 4th minute (p < 0.001) illustrating the nadir point. In the 10thminute, ionized calcium did not show a statistical increase compared to the 4th minute (p = 0.451). The iPTH levels ranged from 34.8 ± 18.6 to 34.1 ± 18.8 pg/mL (similar values between base line and 4thminute p = 0.087) and did not change in the 10th minute (33.3 ± 19,6 pg/ mL p = 0.693). Conclusion: Among CKD patients tested 6-12 months after surgery, grafted parathyroid tissue revealed a blunted secretory capacity during bicarbonate induced hypocalcemia with no changes in iPTH levels.

Autotransplant tissue selection criteria with or without stereomicroscopy in parathyroidectomy for treatment of renal hyperparathyroidism / Influência do critério de seleção de tecido paratiroideano com ou sem estereomicroscopia para autoimplante no resultado do tratamento cirúrgico do hiperparatiroidismo associado a doença renal crônica

INTRODUCTION: Several methods have been proposed to improve operative success in renal hyperparathyroidism. OBJECTIVE: To evaluate stereomicroscopy in parathyroid tissue selection for total parathyroidectomy with autotransplantation in secondary (SHPT)/tertiary (THPT) hyperparathyroidism. METHODS: 118 renal patients underwent surgery from April of 2000 to October 2009. They were divided into two groups: G1, 66 patients operated from April of 2000 to May of 2005, with tissue selection based on macroscopic observation; G2, 52 patients operated from March of 2008 to October 2009 with stereomicroscopy for tissue selection searching for the presence of adipose cells. All surgeries were performed by the same surgeon. Patients presented SHPT (dialysis treatment) or THPT (renal-grafted). Follow-up was 12-36 months. Intra-operative parathyroid hormone (PTH) was measured in 100/118 (84.7%) patients. RESULTS: Data are presented as means. G1 included 66 patients (38 SHPT, 24 females/14 males; 40.0 years of age; 28 THPT, 14 females/14 males; 44 years of age). G2 included 52 patients (29 SHPT, 11 females/18 males; 50.7 years of age; 23 THPT, 13 females/10 males, 44.4 years of age). SHPT patients from G2 presented preoperative serum calcium higher than those of SHPT patients in G1 (p < 0.05), suggesting a more severe disease. Definitive hypoparathyroidism was found in seven of 118 patients (5.9%). Graft-dependent recurrence occurred in four patients, two in each group. All occurred in dialysis patients. CONCLUSION: Stereomicroscopy in SHPT/THPT surgical treatment may be a useful tool to standardize parathyroid tissue selection. .

INTRODUÇÃO: Diversos métodos têm sido propostos com intuito de melhorar índices de sucesso cirúrgico no tratamento do hiperparatiroidismo associado à doença renal crônica (DRC). OBJETIVOS: Avaliar uso do estereomicroscópio na seleção de tecido paratiroideano na paratiroidectomia total com autoimplante em pacientes com DRC. MÉTODOS: 118 pacientes DRC operados entre 04/2000-10/2009 foram divididos em: G1-66 pacientes operados entre 04/2000-05/2005 cuja seleção de tecido foi realizada por método convencional (macroscopia); G2-52 pacientes operados entre 03/2008-10/2009, cuja seleção de tecido foi realizada com uso da estereomicroscopia: Leica-Stereomicroscope (amplificação: 10×-80×). Pacientes foram ainda categorizados em hiperparatiroidismo secundário (HPS) ou terciário (HPT) (HPS-diálise/HPT-transplantados renais). Seguimento pós-operatório: 12-36 meses. PTH intraoperatório medido 100/118 pacientes (84.7%). Todos pacientes foram operados pelo mesmo cirurgião. RESULTADOS: Dados em média. G1, 66 pacientes (38 HPS, 24f/14m; 40 anos; 28 HPT, 14f/14m; 44 anos). G2, 52 pacientes (29 HPS, 11f/18m; 50,7 anos; 23 HPT, 13f/10m; 44,4 anos). Pacientes dialíticos do G2 apresentaram cálcio pré-operatório maior que G1 (p < 0,05), sugerindo doença mais severa. Hipoparatiroidismo definitivo: 7/118 (5,9%) pacientes: G1, 4/66 (6%); G2, 3/52 (5,7%). Recorrência do hiperparatiroidismo no autoimplante: 4 pacientes, 2 em cada grupo. Todas foram em pacientes em diálise. CONCLUSÃO: Estereomicroscopia no tratamento do hiperparatiroidismo associado à DRC é útil na padronização da técnica de seleção de tecido para o autoimplante. .

Definição de valores de corte para medida de PTH intraoperatório no tratamento cirúrgico do hiperparatiroidismo secundário e terciário / Intraoperative PTH cutoff definition to predict successful parathyroidectomy in secondary and tertiary hyperparathyroidism

Avaliamos medida de PTH intraoperatório (IO-PTH) no intuito de melhorar índices de sucesso no tratamento cirúrgico do hiperparatiroidismo associado à doença renal. MÉTODO: Oitenta e seis pacientes realizaram paratiroidectomia total com autoimplante em musculatura pré-esternal entre abril de 2000 e outubro de 2009 com 26,5 meses de seguimento em média, prospectivo. Foram divididos em dois grupos: hiperparatiroidismo secundário (HPS) - pacientes em diálise e hiperparatiroidismo terciário (HPT) - transplantados renais. Medido IO-PTH (Elecsys-PTH-Immunoassay/Roche) na indução anestésica (IOPTH-0') e 20 minutos (IOPTH-20') após a retirada das paratireoides. RESULTADOS: 80,2% (69/86) do total de pacientes apresentaram queda de 80% ou mais do IOPTH-20' e todos se curaram. Em 11/86 (12,7%) pacientes, foi observada queda entre 70-79%, sendo que dois (18,1%) deles evoluíram com falha cirúrgica. 6/86 (6,9%) pacientes apresentaram redução de IOPTH-20' menor do que 70%: dois foram curados; três apresentaram paratireoide supranumerária/ectópica que foi localizada e removida; um paciente evoluiu com persistência da doença após término da cirurgia com a retirada de quatro paratireoides. CONCLUSÃO: Queda do IOPTH-20' de 80% ou mais foi preditor de cura em todos os pacientes renais durante o período avaliado. Redução menor que 70% sugere paratireoide hiperfuncionante não reconhecida/supranumerária, sendo preditor de falha cirúrgica em 66.6%. A queda marginal de 70%-79% delega ao cirurgião experiente a decisão de continuar ou não o procedimento cirúrgico.

In order to improve success rates in surgery of renal hyperparathyroidism, we evaluated intraoperative PTH (IOPTH) measurement utility. METHOD: 86 patients underwent total parathyroidectomy with intramuscular presternal autotransplantation from 04/2000 to 10/2009 and were followed for 26.5 months on average (prospective cohort). Patients were divided in secondary (SHPT) and tertiary hyperparathyroidism (THPT). SHPT group was composed by patients under dialysis treatment, THPT group included renal grafted ones. IOPTH (Elecsys-PTH-Immunoassay/Roche) was measured at anesthesia induction (IOPTH-0') and 20 minutes (IOPTH-20') after parathyroidectomy. RESULTS: 80.2% (69/86) presented with 80% decrease or more in the IOPTH-20' and all were cured. In 11/86 patients (12.7%), a lower IOPTH-20' drop (70-79%) was observed, and 2 of them (18.1%) failed to cure. 6/86 (6.9%) patients presented IO-PTH-20' decrease of less than 70%: two were cured, in three a supernumerary/ectopic parathyroid was found and removed, and in one of these six patients, surgery was finished after 4-gland excision and the patient failure to cure. CONCLUSION: IOPTH-20' decrease of 80% or more compared to IOPTH-0' predicts cure in all renal patients throughout follow-up. A decay of less than 70% points to missed or hyperfunctioning supernumerary gland and is predictive of surgical failure in 66.6%. A marginal IOPTH drop of 70-79% leaves the decision whether or not surgery should be continued up to the experienced surgeon.

Parathyroid carcinoma and hungry bone syndrome / Carcinoma de paratiroide e fome óssea

We hereby report two patients with parathyroid carcinoma presenting extremely high calcium and PTH levels, severe bone disease, and palpable neck mass at diagnosis. They both underwent parathyroidectomy, and one of them evolved to lung metastasis. Important hypocalcemia was observed after surgery in both: after parathyroidectomy in one patient, and only after surgical removal of the metastasis in the other. Both required intravenous calcium replacement, thus revealing hungry bone syndrome (HBS). HBS usually reflects rapid mineralization after correction of hyperparathyroidism. The more severe the bone disease before surgery, the more prone the patient is to HBS after surgery. Despite being an unfavorable outcome, HBS state suggests that surgical removal of hypersecretory parathyroid tissue was accomplished. In this study, HBS was observed in both patients, who presented severe bone disease prior to surgery. HBS would be expected post-operatively in successful parathyroid carcinoma removal.

O presente artigo descreve o relato de dois pacientes com carcinoma de paratiroide que apresentavam valores intensamente elevados de cálcio sérico e de PTH, associado a doença óssea e presença de nódulo cervical palpável ao diagnóstico. Ambos foram submetidos à paratiroidectomia, sendo que um evoluiu com metástases pulmonares. Hipocalcemia importante foi observada após a paratiroidectomia em um paciente e somente após remoção cirúrgica das metástases pulmonares em outro. Ambos necessitaram de reposição endovenosa de cálcio, revelando, assim, o estado de fome óssea (FO). A presença da FO usualmente reflete rápida mineralização óssea após correção do hiperparatiroidismo; assim, quanto mais severa a doença óssea previa à cirurgia, maior será a FO observada no pós-operatório desses pacientes. Embora inicialmente considerada um evento indesejável, a FO representa a bem-sucedida remoção cirúrgica do tecido paratiroideano hipersecretor. Fome óssea deve ser esperada no pós-operatório do tratamento cirúrgico bem-sucedido do carcinoma de paratiroide.

Parathyroid hormone: an early predictor of symptomatic hypocalcemia after total thyroidectomy / Hormônio da paratireoide: um preditor precoce da hipocalcemia sintomática após a tireoidectomia total

OBJECTIVE: The purpose of this study was to evaluate if the measurement of peri-operative parathyroid hormone (PTH) is able to identify patients with increased risk of developing symptoms of hypocalcemia. SUBJECTS AND METHODS: Forty patients who underwent total thyroidectomy were studied prospectively. Ionized serum calcium and PTH were measured after induction of anesthesia, one hour (PTH1) and one day after surgery (PTH24). Patients were evaluated for symptoms of hypocalcemia and treated with calcium and vitamin D supplementation as necessary. RESULTS: Symptomatic hypocalcemia developed in 16 patients. Symptomatic patients had significant lower PTH1 and greater drops in PTH levels. The selection of 12.1 ng/L as PTH1 level cutoff level divided patients with and without symptoms with 93.7% sensitivity and 91.6% specificity. The selection of 73.5% as the cutoff value for PTH decrease resulted in 91.6% sensitivity and 87.5% specificity. CONCLUSION: PTH1 levels and the drop in PTH levels are reliable predictors of developing symptomatic hypocalcemia after total thyroidectomy.

OBJETIVO: O objetivo deste estudo é avaliar se a medida perioperatória do hormônio da paratireoide (PTH) pode identificar os pacientes com maior risco de desenvolver sintomas de hipocalcemia. SUJEITOS E MÉTODOS: Foram estudados quarenta pacientes submetidos à tireodiectomia total. A medida do cálcio sérico e do PTH foi feita após a indução anestésica, uma hora (PTH1) e um dia após a cirurgia. Os pacientes foram avaliados quanto à presença de sintomas de hipocalcemia e tratados com suplementação de cálcio e vitamina D quando necessário. RESULTADOS: Dezesseis pacientes apresentaram sintomas de hipocalcemia. Os pacientes sintomáticos apresentaram PTH1 significantemente menor e queda no PTH significativamente maior. Usando o valor de 12,1 ng/L como corte, conseguimos distinguir pacientes com e sem sintomas de hipocalcemia com sensibilidade de 93,7% e especificidade de 91,6%. Utilizando como corte a queda de 73,5% no valor do PTH, temos sensibilidade de 91,6% e especificidade de 87,5%. CONCLUSÃO: O PTH1 e a queda no PTH são bons preditores de hipocalcemia no pós-operatório de tireoidectomia total.

Utilidade da medida de PTH intra-operatório no tratamento cirúrgico do hiperparatiroidismo primário e secundário: análise de 109 casos / Usefulness of intraoperative PTH measurement in primary and secondary hyperparathyroidism: experience with 109 patients / Usefulness of intraoperative PTH measurement in primary and secondary hyperparathyroidism: experience with 109 patients

INTRODUÇÃO: A medida de PTH intra-operatório (PTH-IO) foi inicialmente descrita em 1988, sendo potencialmente útil na definição de sucesso após a paratiroidectomia. OBJETIVOS: Avaliar prospectivamente perfil de decaimento do PTH-IO e sua capacidade de prever sucesso cirúrgico no hiperparatiroidismo primário (HPP) e secundário à insuficiência renal (HPS). PACIENTES E MÉTODOS: 109 pacientes operados entre 06/2000 e 12/2004, sendo 33 HPP, 76 HPS (52 em diálise, 24 transplantados renais). PTH-IO: método imunométrico rápido (Elecsys-PTH/Immunoassay-Roche); tempo para resultado: 10 minutos. Coletas de sangue periférico nos tempos basal, 10 e 20 minutos pós-paratiroidectomia. RESULTADOS: HPP: queda média de PTH de 79,2 por cento aos 10 minutos. HPS: queda média de PTH de 85,8 por cento e 87,6 por cento aos 10 minutos nos pacientes diálise e transplantados respectivamente. A cirurgia foi bem sucedida em todos, exceto em 2 pacientes (1 HPP, 1 HPS). Em ambos não houve queda PTH-IO, sendo constatado adenoma duplo no HPP e paratiróide ectópica no HPS. CONCLUSÃO: Medida PTH-IO fornece resultados confiáveis em tempo rápido, sendo capaz de discriminar persistência da doença se mantidos níveis elevados.

INTRODUCTION: Intraoperative parathyroid hormone measurement (IO-PTH) was first described in 1988 and it's potentially useful in predicting cure after parathyroidectomy. The aim of this study was to evaluate IO-PTH decay profile and the utility of this procedure in predicting cure in primary (PHH) and secondary (SHH) hyperparathyroidism due to renal disease. PATIENTS AND METHODS: 109 patients were evaluated from 06/2000 to 12/2004. 33 had PHH and 76 SHH (52 in dialysis, 24 with renal graft). IO-PTH was measured at times 0 (before resection), 10, 20 minutes after parathyroidectomy using immunometric assay (Elecsys-PTH/Immunoassay-Roche). Time necessary to perform assay: 10 minutes. RESULTS: HPP patients: IO-PTH average decrease 79.2 percent from basal levels after 10 minutes. HPS: IO-PTH average decrease 85.8 percent and 87.6 percent after 10 minutes in dialysis and renal graft patients respectively. All patients were cured, except 2 (1 PHH, 1 SHH), because of a double adenoma and ectopic (mediastinal) parathyroid respectively. Failure in IO-PTH decrease was observed in both. CONCLUSION: IO-PTH measurement is useful in improving surgical success rates in PHH and SHH.

Cisto de base de língua como causa de tosse crônica / Tongue base cyst as a cause of chronic cough

A tosse é um sintoma muito comum, constituindo-se na segunda causa mais freqüente de procura por consultas médicas. Isso ressalta a importância da identificação e tratamento adequados dos fatores causais relacionados a esse sintoma. Várias doenças que acometem as vias aéreas superiores são comumente associadas à tosse crônica, sendo rara a ocorrência de cistos supraglóticos como etiologia desse sintoma. O presente trabalho descreve o caso de um paciente com tosse crônica devido à presença de um cisto na base da língua. O paciente foi submetido à cirurgia para exérese da lesão, tendo havido desaparecimento do sintoma após o procedimento.

Cough is a very common symptom and it has been considered the second major cause of visits to the doctor. This emphasizes the importance to identify and to treat appropriately the etiological factors that have a relationshipwith this symptom. Several diseases that attack the upper airway are associated to the chronic cough, beingrare the occurrence of supraglottic cysts as an aetiology of this symptom. This paper report a case of a patientwith chronic cough due to a cyst on the tongue basis. The patient was submitted to a surgery and the cyst was completely extracted. The symptom disappeared completely after the procedure.

Doença do refluxo laringofaríngeo / Laryngopharyngeal reflux

O refluxo gastro-esofágico (RGE) é definido como o fluxo retrógrado do conteúdo gástrico (ácido) ou biliar (alcalino) para o esôfago e apresenta-se, principalmente, com sintomas de queimação retro-esternal e regurgitação. Manifestações extra-esofágicas desse refluxo representam uma outra entidade, denominada doença do refluxo laringo-faríngeo (DRLF), e manifesta-se com alterações faríngeas, laríngeas e orais. O esofagograma, a pH-metria, a laringoscopia flexível e a endoscopia digestiva alta (EDA) são considerados os principais exames para o diagnóstico do RLF, cada um com suas vantagens e desvantagens e nenhum com 100% de acurácia isoladamente. O objetivo do tratamento da DRLF é o desaparecimento dos sintomas e a cicatrização das lesões laríngeas, que é realizado com a supressão ácida. Devido às semelhanças entre a DRLF e DRGE, o tratamento clínico baseia-se nos mesmos fundamentos: a instituição de medidas comportamentais e a administração de medicamentos que visam a supressão ácida.

Gastroesophageal reflux has been defined as the retrogradeflow of gastric contents into the esophagus and presents withclassic symptoms of heartburn and regurgitation. Extraesophageal symptoms of this reflux represent another disease named laryngopharyngeal reflux, presenting with laryngeal, pharyngeal and oral manifestations. The diagnosticmodalities frequently used to test for laryngopharyngeal refluxinclude esophagogram, ambulatory pH probe monitoring, flexible laryngoscopy, and upper endoscopy. Each examinationhas its advantages and disadvantages and none offer 100% accuracy. The purpose of the treatment is complete resolution of the symptoms and healing of the laryngeal damage, with isobtained with acid suppression. The standart treatment for laryngopharyngeal reflux is directed at lifestyle, behavioral anddietary modifications and proton pump inhibitors.

Frontal sinus adenocarcinoma

CONTEXT: Paranasal sinus cancer is considered rare, with an incidence of less than 1 per 100,000 per year, with the frontal sinus being the primary site in only 0.3 per cent. We report a case of adenocarcinoma arising in the frontal sinus. DESIGN: Case report. CASE REPORT: A 59-year-old woman, secretary, came in February 1998 with a 4-month history of low intensity frontal headache. She denied contact with wood dust. On examination a non-tender swelling was noted over her right forehead next to the medial aspect of the right orbit. CT scan showed a soft-tissue mass involving frontal sinus with intracranial invasion through the posterior wall. The anterior ethmoid sinus and the medial aspect of the right orbit were also involved. MRI demonstrated dural thickening in communication with the frontal mass. She underwent an en-bloc tumor resection by craniotomy including orbital clearance. Histology revealed an adenocarcinoma. After surgery she had tumor recurrence, and chemotherapy and radiotherapy were started resulting in partial improvement