Hiperparatiroidismo ectópico: Detección de la localización mediastinal / Ectopic hyperparathyroidism. Detection of mediastinal localization

El tejido paratiroideo ectópico es una causa frecuente de recurrencia del hiperparatiroidismo (HPT) siendo de 16% en primarios y 14% en secundarios. La localización intratorácica representa el 20-35%, pero solo un 2% requiere una cirugía torácica. El objetivo fue analizar una cohorte de pacientes con diagnóstico de HPT mediastinal operados en un hospital de alta complejidad de Argentina. Se realizó un estudio retrospectivo de todos los operados por HPT entre enero de 2006 y julio 2019 en ese hospital. Se incluyeron aquellos que requirieron acceso torácico por HPT ectópico. En este período se trataron 728 pacientes con HPT primario y secundario. Seis con primario y 3 con secundario requirieron cirugía torácica. Se realizaron 6 videotoracoscopias (VATS) y 3 esternotomías, sin complicaciones graves. Se utilizó biopsia por congelación en todos y dosaje de paratohormona intraoperatoria (PTHi) en 8 casos, que descendió en promedio 65% respecto al valor basal. Se confirmaron 5 adenomas y 4 hiperplasias. La enfermedad paratiroi dea mediastinal representó el 1.65% (12/728), mientras que recibieron tratamiento quirúrgico en nuestra institución 1.24% (9/728). La biopsia por congelación y el descenso de PTHi resultan útiles para confirmar el foco y eventualmente disminuir el riesgo de recurrencia. La VATS es segura pero depende del entrenamiento y de la disponibilidad en el medio asistencial. Si bien el sestamibi es el método con mayor sensibilidad, se propone el uso de 18F-colina PET/TC ante la sospecha de HPT ectópico. La posibilidad de obtener conclusiones basadas en la evidencia requiere de estudios con mayor número de pacientes.

The ectopic parathyroid tissue is a frequent cause of recurrent hyperparathyroidism (HPT), accounting 16% in primary HPT and 14% in secondary cases. Although intrathoracic ectopic glands represent 25-35% of all ectopic cases, only 2% requires thoracic surgery. The aim of this study is to report a case series of patients with ectopic mediastinal HPT treated by thoracic approach in a private institution in Argentina. This is a retrospective analysis from January 2006 to June 2019. All patients diagnosed with ectopic hyperparathyroidism who required a thoracic surgical approach were included. During this period, 728 patients with primary HPT and secondary HPT were treated. Six with primary HPT and 3 with secondary HPT required a thoracic approach. Six video-assisted thoracoscopy surgeries (VATS) and 3 sternotomies were performed. None of them presented serious posoperative complications. Frozen section biopsy was used in all cases. iPTH was measured in 8 cases, with a mean drop of 65% after 15 minutes. Final pathology reports confirmed 5 adenomas and 4 hyperplasias. Our case series reported an incidence of 1.65% (12/728) mediastinal parathyroids, while 1.24% (9/728) received surgical treatment at our institution. Intraoperative frozen section and PTHi are useful to confirm the diagnosis and to avoid recurrences. Although VATS is a safe and efficient treatment option, it depends on surgical training and availability. In terms of diagnostic imaging resources, sestamibi remains the current gold standard. However, 18F-choline PET/CT may arise as a new diagnostic tool. The possibility of obtaining evidence-based conclusions requires studies with higher number of patients.

Hiperparatiroidismo persistente debido a paratiromatosis / Persistent hyperparathyroidism due to parathyromatosis

RESUMEN La paratiromatosis se describe como una dolencia en la que existen múltiples nódulos de tejido paratiroideo hiperfuncionante diseminados por cuello y el mediastino, en la cual las pruebas de imagen no son efectivas para localizar las glándulas paratiroides y requiere de la combinación de un tratamiento médico y quirúrgico que en ocasiones se presenta como un desafío. Describimos el caso de una mujer de 61 años con hiperparatiroidismo primario recurrente a la que se le extirpan un total de 9 glándulas paratiroideas en 3 cirugías diferentes, y realizamos revisión de la literatura.

ABSTRACT Parathyromatosis is described as a condition in which there are multiple nodules of hyperfunctioning parathyroid tissue disseminated by the neck and mediastinum. Imaging tests are not effective in locating the parathyroid glands and requires the combination of medical and surgical treatment that sometimes is challenging. We describe the case of a 61-year-old woman with recurrent primary hyperparathyroidism. A total of 9 parathyroid glands where removed in 3 different surgeries. We also reviewed the literature.

Crisis hipercalcémica causada por adenoma paratiroideo: reporte de un caso clínico / Hypercalcemic crisis due to parathyroid adenoma: report of a clinical case

La hipercalcemia es un trastorno común que representa aproximadamente el 0,6% de todas las admisiones médicas agudas. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las dos causas más comunes de elevación de los niveles séricos de calcio; constituyen, en conjunto, alrededor del 90% de todos los casos. La presentación sintomática clásica de la hipercalcemia se observa con relativa poca frecuencia en el mundo desarrollado; la presentación más común es la detección asintomática en las pruebas bioquímicas. Sin embargo, en casos raros, el HPTP puede desarrollar hipercalcemia aguda, grave y sintomática, llamada crisis hipercalcémica (CH). Esta condición se asocia a alteraciones profundas en el estado mental y las funciones cardíaca, renal y gastrointestinal en presencia de concentraciones marcadamente elevadas de calcio sérico y paratohormona (PTH). Mientras que algunas elevaciones en el calcio sérico pueden ser bien toleradas, los síntomas de la CH son severos. Si el tratamiento se retrasa, la CH puede provocar la muerte. Describimos el caso de un paciente masculino que ingresa en la unidad de cuidados críticos por una CH secundaria a un HPTP por adenoma paratiroideo. (AU)

Hypercalcaemia is a most common disorder, accounting for approximately 0,6% of all acute medical admissions. Primary hyperparathyroidism (PHPT) and malignancy are the two most common causes of increased serum calcium levels, together accounting for about 90% of all cases. The classical symptomatic presentation of hypercalcaemia is seen relatively rarely in the developed world, the most common presentation being asymptomatic and detected following on biochemical testing. However, in rare cases HPTP can result in acute, severe and symptomatic hypercalcemia, called hypercalcemic crisis (HC). This condition is associated with profound disturbances in mental status, and cardiac, renal, and gastrointestinal function in the presence of markedly increased serum calcium and parathyroid hormone (PTH) concentrations. While some elevations in serum calcium can be well tolerated, symptoms of HC are severe. If treatment is delayed, HC can result in death. We describe herein a case of a male patient who was admitted to the intensive care unit as a consequence of HC resulting from elevated PTH, secondary to a parathyroid adenoma. We describe the case of a male patient who was admitted to the critical care unit for a HC mediated by PTH secondary to a parathyroid adenoma. (AU)

Análisis de falsos negativos en la cintigrafía SPECT de paratiroides con sestamibi en pacientes con hiperparatiroidismo primario sometidos a cirugía entre 2008-2015 en hospital universitario / False negative spect parathyroid scintigraphy with sestamibi in patients with primary hyperparathyroidism

Background: 99mTc-sestamibi parathyroid SPECT scintigraphy is a useful tool in the pre-operative study of hyperparathyroidism. False negatives (FN) have been reported in 5.7-14% of the examinations. Aim: To characterize 99mTc-sestamibi FN in cases referred for primary hyperparathyroidism (PHP) to a university hospital. Material and Methods: Descriptive retrospective analysis. We included patients with PHP, studied with SPECT scintigraphy, operated at our center between 2008 and 2015. Clinical and surgical data were recorded; biopsies of the FN were blindly reviewed by one pathologist. Results: One hundred twenty one scintigraphies fulfilled the inclusion criteria. Seven (5.8%) were negative and 114 positive. There was no difference in age, sex and PTH levels between FN and true positive scintigraphies. At surgery, one FN case had two hyperplasic glands and two cases had ectopic glands. Pathology reported adenoma in three cases, hyperplasia in three and carcinoma in one. The largest diameter of the lesion was lower in FN (1.3 and 2.1 cm respectively, p = 0.02) and the proportion of adenomas was higher in true positive cases (29% and 75% respectively; p < 0.01). The interval between scintigraphy and parathyroidectomy was greater in FN with a median of 92 days (range 20 days-3.2 years, p < 0.01). The percentage of oxyphilic cells observed was similar in both groups. Conclusions: FN parathyroid SPECT scintigraphies in PHP are uncommon. They corresponded to lesions under the equipment's resolution limit and resulted in longer time lags between scintigraphy and surgery.

Correlación entre el nivel preoperatorio de paratohormona y el volumen y peso del adenoma de glándula paratiroides extirpado, en pacientes con hiperparatiroidismo primario mejorados / Correlation of preoperative parathormone level with estimated volume and weight of the parathyroid adenoma in patientes with primary hyperparathyroidism

Introducción: El hiperparatiroidismo primario (HPT1°) es la causa más frecuente de hipercalcemia en la población ambulatoria general. Así mismo, es la indicación más frecuente de cirugía paratiroídea, habitualmente causado por la presencia de un adenoma único, que se asocia a un elevado nivel de paratohormona (PTH). Objetivo: Determinar si existe una relación matemática positiva entre el nivel de PTH preoperatoria y el volumen y peso del adenoma extirpado. Material y Método: Se revisaron retrospectivamente los resultados de las biopsias y PTH preoperatoria de 71 pacientes evaluables con diagnóstico de HPT1° por adenoma único, mejorados. Resultados: Se obtuvo una correlación matemática positiva, aunque débil, entre peso, volumen y PTH preoperatoria. La correlación matemática fue positiva y fuerte entre peso y volumen. Conclusiones: Existe una relación positiva débil entre el peso y volumen y los niveles preoperatorios de PTH. Estos aspectos estudiados son útiles pero especialmente en relación con otros hallazgos pre e intraoperatorios.

Background: Primary hyperparathyroidism is caused mostly by a single adenoma and it is the most frequent cause of hypercalcemia in outpatients. Hyperplasia of the four glands and cancer are the other ethiological diagnosis. It has been postulated that the bigger and heavier an adenoma is the higher the preoperative PTH level. Objective: To evaluate a mathematical relation between adenoma estimated volume and weight and preoperative parathormone level (prPTH). Method: Retrospective analysis of 71 evaluable treated patients biopsies and preoperative PTH level. Results: A mathematical positive and weak correlation between volume, weight and preoperative PTH was obtained. This correlation was positive and strong between volumen and weight. Conclusions: In this group we found a positive and weak mathematical relation between weight, volume and preoperative PTH levels. These aspects alone are useful but only in combination with others for the correct interpretation of pre and intraoperative findings.

Diagnosis and management of primary hyperparathyroidism: a scientific statement from the Department of Bone Metabolism, the Brazilian Society for Endocrinology and Metabolism / Diagnóstico e manejo do hiperparatireoidismo primário: uma posição científica do Departamento de Metabolismo Ósseo, a Sociedade Brasileira de Endocrinologia e Metabolismo

OBJECTIVE: To conduct a literature review on the diagnosis and management of primary hyperparathyroidism including the classical hipercalcemic form as well as the normocalcemic variant. MATERIALS AND METHODS: This scientific statement was generated by a request from the Brazilian Medical Association (AMB) to the Brazilian Society for Endocrinology as part of its Clinical Practice Guidelines program. Articles were identified by searching in PubMed and Cochrane databases as well as abstracts presented at the Endocrine Society, Brazilian Society for Endocrinology Annual Meetings and the American Society for Bone and Mineral Research Annual Meeting during the last 5 years. Grading quality of evidence and strength of recommendation were adapted from the first report of the Oxford Centre for Evidence-based Medicine. All grades of recommendation, including "D", are based on scientific evidence. The differences between A, B, C and D, are due exclusively to the methods employed in generating evidence. CONCLUSION: We present a scientific statement on primary hyperparathyroidism providing the level of evidence and the degree of recommendation regarding causes, clinical presentation as well as surgical and medical treatment.

OBJETIVO: Conduzir uma atualização das últimas evidências científicas a respeito da apresentação, do diagnóstico e do manejo clínico e cirúrgico do hiperparatireoidismo primário clássico e normocalcêmico. MATERIAIS E MÉTODOS: Este documento foi concebido pelo Departamento de Metabolismo Ósseo da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM) a partir daquele oriundo do Programa de Diretrizes da Associação Médica Brasileira (AMB) da SBEM. Realizamos uma revisão dos artigos mais relevantes obtidos nos bancos de dados PubMed e Cochrane, além de abstracts apresentados nos encontros anuais da Endocrine Society, da Sociedade Brasileira de Endocrinologia e da American Society for Bone and Mineral Research dos últimos cinco anos, e classificamos as evidências em níveis de recomendações de acordo com a força científica por tipo de estudo, adaptando o primeiro relato do "Oxford Centre for Evidence-based Medicine". Todos os graus de recomendação, incluindo-se o "D", foram basea-dos em evidência científica, sendo as diferenças entre o A, B, C e D devidas exclusivamente ao desenho empregado na geração da evidência. CONCLUSÃO: Apresentamos uma atualização científica a respeito do hiperparatireoidismo primário, classificando e graduando em níveis de recomendações as principais evidências científicas sobre as suas causas, as variadas formas de apresentação, seu diagnóstico e tratamento.

Patología hiperparatiroidea atendida en tres hospitales costarricenses / Hyperparathyroid pathology treated in three Costa Rican hospitals

Objetivo: determinar la frecuencia y características de los pacientes que por patología hiperparatiroidea, se atendieron en los hospitales México, San Juan de Dios y "Dr. Rafael Angel Calderón Guardia", en un periodo de tres años. Métodos: análisis de registros de parathormona intacta sérica elevada, expedientes clínicos y revisión bibliográfica. Estudio descriptivo, cuya muestra fue pacientes hiperparatiroideos atendidos entre enero 2007 y diciembre 2009. La determinación de frecuencias y proporciones para las variables cualitativas se realizó por medio de la prueba chi cuadrado, y las cuantitativas, mediante la estimación de la prueba t de student. Resultados: de 199 pacientes estudiados, se excluyeron 9. El sexo femenino predominó (68.9 por ciento), el grupo etario más frecuente fue de 60 y más años de edad (33,1 por ciento). El hiperparatiroidismo primario fue la enfermedad más frecuente (n=46;24,2 por ciento;73,9 por ciento mujeres, 69,5 por ciento mayores de 50 años), luego hipovitaminosis D y falla renal crónica. La mayoría vivía en San José (59,4 por ciento) y se atendió en el Hospital México (65,8 por ciento). No se posee el concepto claro y se desdeña el hiperparatiroidismo normocalcémico, por parte de algunos médicos, y la mayoría no solicita determinaciones de vitamina D. Discusión: los pacientes con parathormona intacta elevada por diversas causas están expuestos a muchas patologías que pueden comprometer su sobrevivencia y calidad de vida. La hipovitaminosis D probablemente sería más frecuente, si su medición se solicitara más. Debe enfatizarse la solicitud de calcecifediol en cualquier patología paratiroidea...

Supernumerary parathyroid glands in hyperparathyroidism associated with multiple endocrine neoplasia type 1 / Paratireoides supranumerárias em hiperparatireoidismo primário associado a neoplasia endócrina múltipla tipo 1

OBJECTIVE: To evaluate frequency, anatomic presentation, and quantities of supernumerary parathyroids glands in patients with primary hyperparathyroidism (HPT1) associated with multiple endocrine neoplasia type 1 (MEN1), as well as the importance of thymectomy, and the benefits of localizing examinations for those glands. METHODS: Forty-one patients with hyperparathyroidism associated with MEN1 who underwent parathyroidectomy between 1997 and 2007 were retrospectively studied. The location and number of supernumerary parathyroids were reviewed, as well as whether cervical ultrasound and parathyroid SESTAMIBI scan (MIBI) were useful diagnostic tools. RESULTS: In five patients (12.2%) a supernumerary gland was identified. In three of these cases (40%), the glands were near the thyroid gland and were found during the procedure. None of the imaging examinations were able to detect supernumerary parathyroids. In one case, only the pathologic examination could find a microscopic fifth gland in the thymus. In the last case, the supernumerary gland was resected through a sternotomy after a recurrence of hyperparathyroidism, ten years after the initial four-gland parathyroidectomy without thymectomy. MIBI was capable of detecting this gland, but only in the recurrent setting. Cervical ultrasound did not detect any supernumerary glands. CONCLUSION: The frequency of supernumerary parathyroid gland in the HPT1/MEN1 patients studied (12.2%) was significant. Surgeons should be aware of the need to search for supernumerary glands during neck exploration, besides the thymus. Imaging examinations were not useful in the pre-surgical location of these glands, and one case presented a recurrence of hyperparathyroidism.

OBJETIVO: Avaliação da frequência, da localização anatômica e do número de paratireoides extranumerárias em pacientes com hiperparatireoidismo primário (HPT1) associado a neoplasia endócrina múltipla tipo 1(NEM1), além da avaliação da importância da timectomia e da utilidade dos exames radiológicos para localização destes. MÉTODOS: Foram avaliados de forma retrospectiva 41 pacientes portadores de NEM1 com HPT1 submetidos a paratireoidectomia entre 1997 e 2007. O número de glândulas supranumerárias encontradas e a sua localização foram revisados, assim como a utilidade do ultrassom cervical e do SESTAMIBI (MIBI) de paratireoide como ferramentas diagnósticas. RESULTADOS: Em cinco pacientes (12,2%) foram identificadas glândulas supranumerárias. Em três destes (40%), as glândulas estavam próximas à glândula tireoide e foram encontradas durante a exploração cirúrgica. Os exames de imagem não foram úteis para a localização destas glândulas. Em um caso, apenas o exame anatomopatológico foi capaz de encontrar uma glândula extranumerária microscópica localizada no timo. No último caso, uma quinta glândula foi ressecada por meio de esternotomia após a recidiva do hiperparatireoidismo, cerca de 10 anos após a paratireoidectomia realizada sem timectomia na ocasião. Neste caso o MIBI detectou esta paratireoide apenas após a recidiva da doença. Em nenhum dos casos o ultrassom cervical foi capaz de detectar glândulas extranumerárias. CONCLUSÃO: A frequência de paratireoides supranumerárias em nossa casuística foi significativa (12,2%). Durante a exploração cervical, o cirurgião deve estar atento para localizar glândulas extranumerárias além do timo. Exames de imagem não foram úteis na localização préoperatória dessas glândulas, e em um caso houve recidiva do hiperparatireoidismo.

A Rare Case of Primary Hyperparathyroidism Associated with Primary Aldosteronism, Hurthle Cell Thyroid Cancer and Meningioma

Multiple endocrine neoplasia type 1 (MEN1) syndrome includes varying combinations of endocrine and non-endocrine tumors. There are also a considerable number of atypical MEN1 syndrome. In this case, a 68-yr-old woman was referred to the Department of Endocrinology for hypercalcemia. Five years ago, she had diagnosed as primary hyperaldosteronism and now newly diagnosed as parathyroid hyperplasia with laboratory and pathologic findings. Hurthle-cell thyroid cancer was also resected during the parathyroid exploration and small meningioma was found on brain MRI. Her general condition has markedly improved and her adrenal mass and meningioma are being closely observed now. We could find the loss of heterozygosity of the MEN1 locus in parathyroid glands, suggesting a MEN1-related tumor, but not a germline mutation. Considering a variety of phenotypic expression and a limitation of current molecular analysis, periodic follow up will be needed in patients with a MEN1-like phenotype.

Abordaje periauricular en las lesiones de la glándula parótida / Parothid glan lesions incision aroud ear

Evaluar la posibilidad de resección de las lesiones de la glándula parótida por incisiones periauriculares (grupo I) y valorar las complicacionesin mediatas derivadas de esta técnica, resultados cosméticos y dolor posoperatorio, comparándolas con el abordaje preauricular-transcervical (grupo II). Los 61 pacientes, de ambos sexos, entre julio de 2006 a julio de 2009, fueron sometidos a este estudio prospectivo, aleatorizado doble ciego, evaluando dos grupos, categorizados grupo I yII, haciendo comparaciones en cuanto a dolor posoperatorio según la escala analógica de niveles de dolor, complicaciones relacionadas al nervio facial, posibilidad de resección indistintamente del tipo histológico, del lóbulo afectado, y por último, la satisfacción cosmética. Los 59 pacientes completaron este estudio, no obteniendo diferencias estadísticamente significativas en cuanto al dolor posoperatorio, ni en cuanto a las complicaciones, pero si en lo referido a la visualización de la cicatriz operatoria; 96% de los pacientes (grupo I), refirió satisfacción con el resultado cosmético en comparación con 65% del grupo II; siendo estadísticamente significante. No hubo diferencias en cuanto a la presentación de dolor ni complicaciones posoperatorias en cuanto al abordaje periauricular en comparación a los que se les realizó el abordaje preauricular-transcervical. Fue mayor la manifestación de satisfacción cosmética en el abordaje periauricular, la cual recomendamos, porque no produce dificultades técnicas, indistintamente del sexo, edad, tipo histológico o ubicación de la lesión dentro de la glándula parótida.

To evaluate the possibility of resection of the lesions of the parotid gland by the incisions around the ear (Group I) and assess immediate complications arising fromthis technique, the cosmetics results and the post operative pain, comparing them with the ahead ear - transcervical approach (Group II). In 61 patients of both sex, from July 2006 to July 2009, were subjected to this prospective study, and randomized double blind, evaluating the two groups, categorized group I and II, making comparisons on post operative by the analog levels of the pain, complications related to the facial nerve, possibility of resection regardless of the histological type, the affected lobe, and finally, the cosmetic satisfaction. The 59 patients that completed this study, no statistically significant differences we found in the post operative pain getting. There were no differences also on complications, but if in connection with the post operative scar, the 96%patients (Group I), spoke to us, their satisfaction with the cosmetic outcome compared with 65% of Group II; that being statistically significant. There was no differences as regards the presentation of the painor the post operating complications in the around ear compared to the ahead ear - transcervical approach. The manifestation of cosmetic satisfaction in around ear were approach, we recommend it because it does not produce technical difficulties, without any distinction of sex, age, histological type, or location into the parotid gland.

Hiperparatiroidismo primario de origen multiglandular con glándula paratiroides intratiroídea hiperfuncionante / Multiglandular primary hyperparathyroidism with a hyperfunctional intrathyroid gland: case report

We report a 56 years old female, admitted to the hospital for the study of general weakness, constipation, a recent radial fracture, hypercalcemia of 18 mg/dl, hypophosphatemia of 1.2 meq/dl and a serum parathormone (PTH) of 995 pg/ml. A thyroid ultrasound disclosed a nodule of 6 cm diameter. Following emergency management and normalization of the hypercalcemia, that patient was subjected to a total thyroidectomy and parathyroidectomy. The pathological study of the surgical piece showed a multiglandular hyperplasia of the parathyroid glands. One of these was located inside the left thyroid lobe.

Se presenta el caso de una paciente de 56 años que ingresó al hospital por una historia caracterizada por decaimiento, constipación, fractura reciente de radio, hipercalcemia de 18 mg/dl, hipofosfemia de 1,2 meq/ dl y elevación de paratohormona de 995 pg/ml. Además, presentaba un nódulo tiroídeo de 6 cm. Posterior al tratamiento médico de la hipercalcemia, se realizó el tratamiento quirúrgico con el diagnóstico definitivo de hiperplasia paratiroídea multiglandular con una de ellas en ubicación intratiroídea.

Ultrasonography for early detection of enlarged secondary parathyroid gland in patient with end stage renal disease: prediction by clinical features

To determine the association between the numbers of clinical features either due to end stage renal failure [ESRF] or Secondary hyperparathyroidism [SHPT] and size of parathyroid gland. An analytical study was carried out between 1[st] of January to 30[th] of June of 2006 by the collaboration of nephrology centre and radiology department of Al-Noor Specialist Hospital, Makkah, Saudi Arabia. Patients with [ESRF] on hemodialysis for more than 12 months, receiving medical treatment who had increased parathyroid hormone level with more than one clinical features of hyperparathyroidism were selected. Subjects were divided into two categories, having enlarged [A] and not enlarged [B] parathyroid glands. Ultrasonographic examinations of the neck were performed by using high frequency transducers in the range of 7.5 to 10 MHz by using Aloka pro sound 5500 machine. Pearson correlation [r] and linear regression analysis was done between number of clinical features and number of subjects in each category. Only 17[31%] were found to have enlarged gland out of total 54 subjects. Males 32[59%] outnumbered the females. Subjects' Parathyroid hormone ranged from 111-6047 pg/ml with mean 1266 +/- 994 [SD], while for subjects with enlarged glands the range was 820-6047 pg/ml with mean 1645 +/- 804 [SD]. Number of subjects in category A were found to increase with increase in frequency of clinical features by doing regression analysis with correlation coefficient [r=0.98, p=0.002] while category B didn't show any kind of correlation [r=0.36, p>0.54]. Comparison of correlation by Fisher's Z transformation of data a significant difference was found between categories A and B [p<0.05]. Frequency of subjects with enlarged gland increased with increasing number of clinical features

Variations in the anatomical position of the normal and diseased parathyroid glands

Despite the availability of expert surgeons and preoperative imaging investigations, some patients require re-operation for persistent or recurrent hyperparathyroidism. Ectopic Parathyroid Glands [PGs] are a cause for failed parathyroid exploration. To evaluate the prevalence and location of normal parathyroid glands and diseased glands taken from subjects with End-Stage Renal Disease [ESRD]. A total of 410 parathyroid glands were recovered from 116 postmortem subjects of whom 37 were diagnosed as suffering from ESRD. In the rest, the death had resulted from disease unrelated to parathyroid disorder. 155 [69.3%] of both normal left and right superior PGs were located at cricothyroid junction; 46 [29.3%] were behind the upper pole of thyroid gland; 2 [2.6%] were behind pharyngoesophageal junction. 68 [47.1%] of the normal inferior PGs were found at the lateroposterior surface of the lower pole of thyroid gland; 62 [43.7%] were within the thymic tongue and 14 [9.7%] along the carotid artery. The normal ectopic PGs were found only in 22 cases. The superior PGs were 4 [18.2%] in an extracapsular posterior position, 2 [9.1%] intrathyroidal and 1 [4.5%] retropharyngeal. The inferior ectopic PGs were 15 [68.2%] and were found within the mediastinal thymus. 19 [51.4%] of the enlarged PGs were found within the thyroid parenchyma, 8 [21.6%] within the thymic tongue, 6 [16.2%] within the thymus, 2 [5.4%] were within the carotid sheath and 1 [2.7%] in the retropharyngeal or retroesophageal position. The presence of ectopic PGs in secondary hyperparathyroidism is sufficiently important to justify their exhaustive search. As the preoperative image exams present low sensibility to locate them, it is necessary to develop an exploratory routine embracing the most common sites of location

Paratireóides: estrutura, funções e patologia / Parathyroid glands: structure, functions and pathology

Os autores tecem considerações sobre a estrutura e funções normais das glândulas paratireóides como introdução à patologia e as repercussões clinico - patológicas tanto do excesso como da redução do paratormônio. Maior ênfase é dedicada ao hiperparatireoidismo primário quanto às causas, a fisiopatologia das alterações, os aspectos anatomopatológicos macro e microscópicos das lesões e sua patogenia, na "Osteite fibrocistica" ou "doença de von Recklinghausen dos ossos" com a correlação aos aspectos radiográficos. Apresentam caso de paciente, cuja história clinica demonstra as dificuldades encontradas para o diagnóstico da doença. Referem-se ainda às alterações e patogenia das formas de hiperparatireoidismo secundário e terciário e ao hipoparatireoidismo.

The authors present a summary on the normal anatomy and function of the parathyroid glands as well as a brief review of clinical and pathological repercussions of higher and lower parathyroid hormone production. The emphasis is given on the causes, physiopathology, anatomy, macroscopy and microscopy of the lesions and their role in the genesis of fibrocystic osteitis, also known as Von Recklinhausen disease of the bones. Radiological correlation is also given. The authors show the challenges for the diagnosis in the same cases. We also write about secondary and tertiary hyperparathyroidism, as well as hypoparathyroidism.

Hiperparatiroidismo primario en el adolescente: caso clínico / Primary hyperparathyroidism in an adolescent: report of one case

We report a 13 year-old mate with a history of multiple fractures and kidney stones. The laboratory showed a hypercalcemia of 11.5 mg/dl, a PTH of 112.6 pg/ml and 24 hour urinary calcium of 571 mg. Bone densitometry showed spine and fémur Z scores of -2.9 and -1.6, respectively, kidney ultrasound showed nephrocalcinosis and a MIBI-SPECT scintigram showed a higher uptake in the ríght lower parathyroid gland. The diagnosis of primary hyperparathyroidism was made and the patient was operated, excising the ríght lower parathyroid gland. After surgery, serum calcium and PTH levels returned to normal values. In children, the proportion of cases with parathyroid hyperplasia is higher than in adults. Therefore, during surgery all four parathyroid glands must be explored. There is also a higher frequency of ectopic adenomas. Family history must be explored to discard the presence of a multiple endocrine neoplasia (MEN I or II), a familial hyperparathyroidism or a syndrome of primary hyperparathyroidism associated to mandibular tumor.

Ectopic parathyroid adenoma--the hidden culprit.

Primary Hyperparathyroidism is known to present with protean manifestations leading to misdiagnosis in the initial stages of the disease. Inability to locate the adenoma in an ectopic parathyroid gland may further delay the diagnosis of these cases. Aberrant migration during development may lead to intrathyroidal or other ectopic locations of parathyroid glands. This may lead to their misdiagnosis as a thyroid nodule or failure to locate parathyroids during surgery. Similarity in cytological picture between thyroids and parathyroids may further complicate diagnosis by fine needle aspiration cytology. Nuclear imaging scintigraphy accurately localizes the tumor in 90% of cases and simplifies the surgical management. We encountered three such cases with the parathyroid gland adenomas in ectopic locations in which pre-operative nuclear imaging played a major role.

Alcoholización percutánea de glándulas paratiroideas: tratamiento del hiperparatiroidismo secundario, valoración de la eficacia según los niveles de la hormona paratiroidea / Percutánea fortification of paratiroideas glands: treatment of the secondary hiperparatiroidismo, valuation of the effectiveness according to the levels of paratiroidea hormone

Objetivo: La alcoholización percutánea de glándulas paratiroides (APGP)es una opción para el tratamiento de hiperparatiroidismo secundario. El objetivo de este trabajo es describir y determinar la seguridad y eficacia de esta técnica. Material y métodos: Fueron estudiados retrospecrivamente 45 pacientes con insuficiencia renal crónica terminal (IRCT) a los cuales se les realizó alcoholización percutánea de glándulas paratiroideas por contraindicación quirúrgica. Se analizaron los niveles de la hormona paratiroidea (PTH) antes del procedimiento, luego de la última diálisis (PTH-basal) y entre el 1º y 7º día posterior a la alcoholización (PTH-post alcoholización). Resultados: Diceiocho pacientes (47,4%) presentaron disminución de los valores de PTH en un 40% o más, considerándose el resultado del procedimiento exitoso u óptimo; en diez pacientes (26,3%), con una disminución de entre el 20% y el 40%, se valoró como sub-óptimo; en 6 pacientes (15,8%) no se obtuvieron resultados satisfactorios y en 4 pacientes (10,5%) no hubo modificación de los valores de PTH. Veintitrés pacientes del total (51,1%) presentaron complicaciones menores: disfonía (8,9%), dolor (35,6%), hematoma (2,2%), hipocalcemia(2,2%) y tos (2,2%). En ningún caso se presentaron complicaciones mayores. Conclusión: La APGP en los pacientes con hiperparatiroidismo secundario e IRCT es una opción segura y eficaz cuando no es factible la cirugía.