Cohort review of patients with parathyroid cancer in End Stage Renal Disease (ESRD).

BACKGROUND AND HYPOTHESIS: Parathyroid carcinoma (PTTC) is a rare malignant endocrine tumor seen in up to 1-2% of all cases of primary hyperparathyroidism. However, incidence of parathyroid carcinoma in renal hyperparathyroidism is a rare phenomenon. We aimed to evaluate the outcomes of PTTC in renal hyperparathyroidism published in the literature. METHODS: Cohort review of parathyroid cancer cases reported in Medline (via PubMed), COCHRANE and EMBASE between the period 1985 - 2023 in patients with renal hyperparathyroidism. RESULTS: A total of 48 patients (20 M: 28F), with a mean age of 49.8 (± 11.7 SD: range 20-75) years. Dialysis vintage was for a period of 8.9 (± 7.2; range 6 months to 40 years). The mean preoperative values were as follows: serum corrected calcium-2.87 IQR 2.56-3.01), PTH - 221.8 (IQR 86.6 -257.2 pmol/L) and serum phosphate - 2.07 (IQR 1.72-2.28) mmol/L. Preoperative imaging was in the form of ultrasound of the neck in 21 of 48 (44%), MIBI scan in 27/48 (56%), contrast enhanced computerized tomography in 14/48 (29%) and MRI neck in 1/48 (2%). The mean size of the cancer was 2.7 (± 1.35) cm and weight of the gland ranged between 0.9 to 4.98 g. 18/48 (37%) patients underwent a total parathyroidectomy and 30/48 (63%) had subtotal parathyroidectomy. En bloc excision of the tumour along with the thyroid along and central compartment lymph nodes was only performed in 12/48 (25%), of whom 9 (19%) had it performed at index surgery, whereas in the rest was done for persistent or recurrent disease. After a mean follow up of 34 months, 14 (29%) had local recurrence, 1 (2%) had distant metastasis to the skeletal system, and 12 (25%) to the lungs. Cohort mortality was 6 (13%) due to refractory hypercalcemia. CONCLUSIONS: Parathyroid carcinoma in renal hyperparathyroidism is rare but when encountered, en bloc excision with parathyroidectomy provides the best chance of cure. Recurrences can be difficult to treat but may be needed to treat intractable hypercalcaemia.

FT4 is a novel indicator for risk assessment of severe hypocalcemia following parathyroidectomy.

OBJECTIVE: To analyze the risk factors associated with the development of severe hypocalcemia (SH) in patients who have undergone parathyroidectomy (PTX). METHODS: This research involved patients with chronic kidney disease-secondary hyperparathyroidism who underwent PTX between June 1, 2021, and May 31, 2023. SH was characterized by a serum total calcium (tCa) level below 1.8 mmol/L. This study aimed to analyze differences in preoperative laboratory findings and clinical manifestations between patients with and without SH. Logistic regression analysis was used to identify potential risk factors associated with the development of SH. RESULTS: The incidence of SH was 23% (n = 176). Significant differences were observed in free thyroxine (FT4), free triiodothyronine, alanine aminotransferase, osteocalcin, tCa, alkaline phosphatase (ALP), C-terminal cross-linked telopeptide of type I collagen, and parathyroid hormone between the SH and non-SH groups. The three independent risk factors for SH were tCa [odds ratio (OR) 0.063, 95% confidence interval (95% CI) 0.006-0.663], ALP (OR 1.003, 95% CI 1.001-1.005), and FT4 (OR 0.439, 95%CI 0.310-0.621). The area under the curve, sensitivity, specificity, and overall accuracy of this model were 0.904 (95% CI 0.856-0.952), 46.3%(95% CI 32.0%-61.3%), 94.8% (95% CI 89.7%-97.5%), and 83.5% (95% CI 77.3%-88.3%), respectively. CONCLUSION: The preoperative level of FT4 plays a crucial role in predicting the risk of SH after PTX. The combined FT4-ALP-tCa model demonstrates the ability to predict SH risk, providing valuable insights for customizing calcium supplementation strategies and improving clinical decision-making.

Subtotal Versus Total Parathyroidectomy for the Management of Tertiary Hyperparathyroidism: A Systematic Literature Review and Meta-Analysis of Optimal Surgical Modality.

Background: Surgery is the definitive treatment option for tertiary hyperparathyroidism (THPT), however, the optimal surgical approach remains unclear. We aimed to compare total parathyroidectomy (PTX) with auto-transplantation vs subtotal PTX for THPT through a systematic review and meta-analysis.Methods: PubMed, Embase, and Web of Science were searched for studies comparing outcomes of total vs subtotal PTX for THPT. A total of 28 studies (n = 1000 patients) met the inclusion criteria.Results: The mean age was 46.5 years and 53% were female. The proportion of females (59% vs 49%) was higher in the total PTX with auto-transplantation cohort (P = .008). Both procedures had similar preoperative calcium and PTH levels. Postoperative and 6-month calcium and PTH were also comparable between groups, except transiently higher post-operative PTH in the total PTX with auto-transplantation cohort (P = .03). Hypercalcemia cure rates were 98%-100% with no difference between surgical techniques (P = .67). Safety profiles were comparable and low.Conclusions: Total PTX with auto-transplantation and subtotal PTX yield similar efficacy and safety for THPT, with no significant differences in cure rates, recurrence, complications, or biochemical control.

Prevalence, risk factors and effect of curative parathyroidectomy on nephrocalcinosis in Asian-Indian patients with symptomatic primary hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is characterized by inappropriate secretion of parathyroid hormone, causing hypercalcemia and hypercalciuria, leading to renal stone diseases and nephrocalcinosis. The frequency, risk factors, and curative effect on nephrocalcinosis in post-parathyroidectomy have not been identified yet. Therefore, the present study evaluated the clinico-biochemical, radiological parameters and curative effect on nephrocalcinosis. A total of 583 PHPT patients were analysed in four groups viz. Group 1 (PHPT with nephrocalcinosis-98; 16.8%); Group 2 (PHPT with nephrolithiasis-227; 38.9%); Group 3 (PHPT with both nephrolithiasis and nephrocalcinosis-59; 10.1%); and Group 4 (PHPT without renal diseases-199, 34.1%). In the sub-group analysis, younger age (p ≤ 0.05), male gender (p ≤ 0.05), and hematuria (p ≤ 0.005) were significant in Group 1 vs. Group 4. Dysuria and low eGFR were significant in Group 1 vs. Group 2 (p ≤ 0.0005; p ≤ 0.05) and Group 1 vs. Group 4 (p ≤ 0.0005; p ≤ 0.0005). Polyuria (p ≤ 0.05; p ≤ 0.05, p ≤ 0.005), and gravluria (p ≤ 0.05; p ≤ 0.0005, p ≤ 0.005) were frequent in Group 1 vs. other groups. A significant difference was observed in S.Ca and, 24-hrs U.Ca in Group 1 vs. Group 2 {(12.2 (10.8-13.4) vs. 11.2 (10.7-12.4), p ≤ 0.05; 301 (189.5-465) vs. 180 (92.5-323.1), p ≤ 0.05} and Group 1 vs. Group 4 {(12.2 (10.8-13.4) vs. 11.4 (10.7-12.5), p ≤ 0.05 ; 301 (189.5-465) vs. 213 (110-360), p ≤ 0.0005}. Multivariate logistic regression showed gravluria [aOR = 9.2, p = 0.0001], S.Ca (aOR = 1.30, p = 0.003) and, 24-hrs U.Ca (aOR = 1.02, p = 0.042) to be independent predictors of nephrocalcinosis. Pre and post-operative assessment revealed decreased S. Ca levels [(11.9 ± 1.9) vs. (10.5 ± 1.0) mg/dL; p = 0.04] and complete radiological resolution (10.4%) in PHPT with nephrocalcinosis. Therefore, serum calcium, 24-hrs Urinary calcium, and gravluria were independent predictors of nephrocalcinosis with 10.4% showing complete radiological resolution post-operatively.

Analysis of Opioid Prescribing Trends Following Thyroidectomy and Parathyroidectomy Before and After the 2021 American Academy of Otolaryngology-Head and Neck Surgery Opioid Prescribing Clinical Practice Guidelines.

OBJECTIVE: To evaluate the trends in opioid and nonopioid prescribing for thyroidectomy and parathyroidectomy before and after the publication of guidelines by the American Academy of Otolaryngology-Head and Neck Surgery in April 2021. STUDY DESIGN: Retrospective. SETTING: Eighty-three health care organizations in the United States that contribute to the TriNetX database. METHODS: Deidentified patient data were retrieved from the TriNetX. Patients who were prescribed either opioids or nonopioid analgesic within 1 to 5 days following thyroid surgery and parathyroidectomy were included. Evaluation of the prescription trends was performed by interrupted time series analysis in Statistical Analysis System 9.4 with significance set at P < .05 to assess trends before and after the new opioid prescription guidelines. RESULTS: For thyroid surgery, there was an immediate effect of the guideline change indicated by a 3.3% decrease in the opioid prescription trend (P = .03) and a significant increase in nonopioid use of overtime by 0.13% every 3 months (P < .0001). The opioid prescription trend following parathyroidectomy significantly decreased over time by 0.28% every 3 months (P < .0001), while the nonopioid prescription trend increased by 0.14% (P < .0001). CONCLUSION: There was an associated immediate reduction in the opioid prescribing trend for thyroidectomy, but the change was not sustained overtime. There was an associated decrease in the opioid prescribing trend for parathyroidectomy, but not immediately after the initial publication of the prescription guidelines. LEVEL OF EVIDENCE: Level III.

Patient Neighborhood Adversity Associated With Access Not Wait Time to Parathyroidectomy.

INTRODUCTION: Delays to treatment of primary hyperparathyroidism (PHPT) escalates patient morbidity, which particularly affects individuals from under-resourced areas already facing health disparities. We hypothesized that PHPT patients from socially and economically deprived areas encounter longer waits to surgery. METHODS: Utilizing a prospectively maintained database, we identified PHPT patients aged ≥18 undergoing initial parathyroidectomy between 2013 and 2022 at an academic, tertiary care center. Patient's social and economic advantage levels were classified into deciles using the Area Deprivation Index (ADI), which accounts for 17 social determinants of health. The time from first hypercalcemic value to surgery was compared across ADI groups via linear regression, controlling for pertinent care process factors. RESULTS: Among 1132 patients, 68.9% were from low, 19.1% from medium, and 12.0% from high-disadvantage areas, diverging from the hospital's catchment population (55.2%, 26.6%, and 18.1%, respectively, P < 0.01). Patients from high-disadvantage areas exhibited higher comorbidity rates (55.2% versus 38.2%, P < 0.01) and were predominantly rural residents (66.2% vs. 5.8%, P < 0.01) compared to low-disadvantage areas. Similar biochemical and clinical features were shown across ADI groups. The median time from abnormal calcium to surgery was 648 d (IQR 543-753), with high-disadvantage patients experiencing a median treatment delay of 527 d, compared to 657 and 633 d for medium and low-disadvantage patients, respectively (P = 0.38). Linear regression analysis showed no association between ADI and treatment delay. CONCLUSIONS: The high-disadvantage group underwent parathyroidectomy at lower rates than expected, but there were no significant delays in surgery among disadvantaged patients who were ultimately treated. This suggests that while social determinants may correlate to care access, they do not necessarily prolong treatment for those with established care.

Parathyroidectomy reduces inflammatory cytokines and increases vitamin D metabolites in patients with primary hyperparathyroidism.

CONTEXT: Primary hyperparathyroidism (PHPT) is accompanied by a decreased 25-hydroxyvitamin D (25OHD) and vitamin D binding protein (DBP). High parathyroid hormone (PTH) is associated with elevated interleukin-6 (IL-6) and monocyte chemoattractant protein-1 (MCP-1), yet the role of parathyroidectomy (PTX) on DBP and cytokines is not clear. OBJECTIVE: To prospectively evaluate the effect of PTX on inflammatory profiles, total and free 25OHD, and DBP in patients with PHPT. METHODS: Newly diagnosed patients with PHPT were recruited in the study (n=70). Twenty-eight patients returned after PTX, 3 months later. Biochemical markers were measured before and after PTX. A group of age and BMI-matched healthy subjects were included as controls (n=70). RESULTS: Prior to PTX, patients had lower serum DBP (37.5±6.0 vs 41.5±6.1mg/dL, p<0.001) and total 25OHD (30.1±9.5 vs 33.3±7.9ng/mL, P<0.05), but similar free 25OHD when compared to controls. Serum IL-6, C-reactive protein (CRP), and MCP-1 were higher in PHPT patients (p<0.05), whereas interleukin-10 (IL-10) was similar to controls. PTX increased total and free 25OHD and DBP (p<0.001), and decreased serum IL-6 and MCP-1 (p<0.05), but not CRP and IL-10. Multiple regression analysis indicated that the preoperative PTH explained a significant portion of the variance of IL-6 and MCP-1 (p<0.05). CONCLUSIONS: These findings suggest that PTH may upregulate the production of MCP-1 and IL-6 and downregulate circulating DBP in patients with PHPT, that are normalized by PTX. The exact effect of IL-6 and MCP-1 on DBP, vitamin D metabolites and the role on clinical outcomes in patients with PHPT is an area requiring further study.

The role of anatomical and functional orientation in identification of parathyroid glands for patients with parathyroidectomy.

Objective: To investigate diagnostic approaches for preoperative localization of secondary hyperparathyroidism, as well as to give surgeons with precise parathyroid gland localization and imaging so that surgery can be performed safely. Methods: The clinical data of 710 patients with secondary hyperparathyroidism who underwent surgery in our center from October 2009 to October 2023 were retrospectively analyzed. The changes in calcium, phosphorus, and parathyroid hormone levels were observed to ascertain the anatomical location and number of parathyroid glands. Results: Among the 710 patients, 55 underwent total parathyroidectomy, the others underwent total parathyroidectomy with autotransplantation. In total, 2,658 parathyroid glands were removed, with 43 glands being removed in 35 reoperation cases. The median parathyroid hormone level at 6 months postoperatively was 13.40 (interquartile range, 7.00-29.80) pg/mL. The detection rates of the parathyroid glands before first and repeat surgeries were higher using 99mTc-MIBI SPECT/CT fusion imaging than ultrasound (P<0.05). The sensitivity of combined preoperative 99mTc-MIBI SPECT/CT and ultrasound was 92.31%, higher than that of either 99mTc-MIBI SPECT/CT fusion imaging or ultrasound alone (P < 0.05). The incidence of ectopic parathyroid glands was 23.8%, and the incidence of ectopic left lower parathyroid glands was 13.2%. The left lower parathyroid gland was the most prone to ectopia. Conclusion: 99mTc-MIBI SPECT/CT fusion imaging, paired with high-frequency ultrasound, can be utilized to diagnose SHPT preoperatively. The most common ectopia site is the left lower parathyroid gland, which is located primarily in the thymus and superior mediastinum. Understanding the functional anatomical distribution of the parathyroid glands is critical for developing effective surgical methods for secondary hyperparathyroidism.

Atypically presented dysphagia in a patient with primary hyperparathyroidism that resolved after parathyroidectomy: A case report.

INTRODUCTION: Dysphagia is a rare initial manifestation of primary hyperparathyroidism, which typically presents with gastrointestinal symptoms like anorexia and constipation. This case presentation aims to describe swallowing difficulty as a potential primary symptom of parathyroid hormone (PTH)-mediated hypercalcemia. PRESENTATION OF CASE: An elderly Palestinian female presented with a two-year history of progressive dysphagia, along with mood disturbances and increased urination. Her medical history included osteoporosis and hyperparathyroidism. Laboratory tests showed elevated PTH and calcium levels. Imaging, including neck ultrasound (US) and Tc99m sestamibi scan, identified a parathyroid adenoma. Despite normal findings on esophagogastroduodenoscopy, a focused single parathyroidectomy was performed. Post-surgery, the patient's dysphagia resolved completely, and her calcium and PTH levels normalized. DISCUSSION: This case highlights an atypical presentation of PTH-mediated hypercalcemia where dysphagia was the primary symptom. Literature review shows similar cases where parathyroid adenomas presented with unusual symptoms, emphasizing the need for thorough diagnostic evaluation. The resolution of dysphagia following surgery suggests a likely correlation between hypercalcemia and dysphagia, implying a possible causative association. CONCLUSION: This case demonstrates dysphagia as a rare but significant symptom of hypercalcemia in a patient with a small parathyroid adenoma. Considering its size, it was unlikely to cause dysphagia through mechanical obstruction. Thus, a functional cause linked to hypercalcemia was likely to be the cause of dysphagia. Surgical removal of the adenoma resulted in resolution of symptoms. A literature review was performed, which revealed similar cases of dysphagia related to hypercalcemia, supporting the fact that in this patient, dysphagia was related to the hypercalcemia.

Variation in PTH levels and kinetics after parathyroidectomy.

Intraoperative parathyroid hormone (IOPTH) is a surgical adjunct used to assess function of remaining parathyroid glands in "real-time" during parathyroidectomy. Parathyroid degradation kinetics are affected by timing of blood draws, patient characteristics, and disease phenotype. A nuanced understanding of these multiple factors can help parathyroid surgeons interpret IOPTH results. This article summarizes recent literature on PTH kinetics with a focus on how to apply this knowledge clinically during parathyroid surgery.

Factors associated with dysfunction of autogenous arteriovenous fistula in patients with secondary hyperparathyroidism after parathyroidectomy.

BACKGROUND: Secondary hyperparathyroidism (SHPT) is a prevalent chronic complication in patients undergoing hemodialysis. Parathyroidectomy (PTX) is crucial for reducing mortality and improving the prognosis in the treatment of refractory hyperparathyroidism. However, it is often associated with a number of postoperative complications such as postoperative hypotension, hyperkalemia, and hungry bone syndrome. A previous study demonstrated that low blood pressure influences the patency of autogenous arteriovenous fistulas (AVF). Few studies have examined AVF dysfunction following PTX. This study aimed to identify and describe the risk variables associated with AVF dysfunction after PTX. METHODS: Cases of AVF dysfunction after PTX between 2015 and 2021 were studied. Four controls were identified for each patient and were matched for sex and age. Biochemical parameters and blood pressure of the patients before and after PTX were recorded. Risk factors for AVF dysfunction after PTX were identified using conditional logistic regression analysis. RESULTS: Sixteen patients and 64 controls were included in this study. Baseline demographic and laboratory data were compared. Patients in the AVF dysfunction group had lower levels of postoperative calcium than the controls. After surgery, calcium levels decreased more in patients with AVF dysfunction than in the control group. The decrease in systolic blood pressure (ΔSBP) after PTX was greater in the AVF dysfunction group than that in the control group. For each 1 mmHg increment in ΔSBP, the risk of AVF dysfunction after surgery increased by 11.6% (OR = 1.116, 95% CI, 1.005-1.239, p = .040). The likelihood of developing AVF dysfunction after surgery was twelvefold higher in diabetic patients than in non-diabetic patients (OR = 12.506, 95% CI, 1.113-140.492, p = .041). Among patients with ΔSBP > 5.8 mmHg after PTX, the AVF failure rate was significantly greater in patients with diabetes than in those without diabetes. Patients with a history of AVF failure had a nine-fold higher risk of developing AVF dysfunction (OR = 9.143, 95% CI, 1.151-72.627, p = .036). Serum albumin, hemoglobin, ΔiPTH, and age were not independent predictors of AVF dysfunction. The cutoff value for SBP was 5.8 mmHg, as determined by the Youden index of the receiver operating characteristic curve. CONCLUSION: Decreased systolic blood pressure (ΔSBP) after PTX, diabetes, and AVF failure history were risk factors for AVF dysfunction following PTX in patients with SHPT. Diabetes patients with ΔSBP > 5.8 mmHg were more prone to AVF dysfunction after PTX.

Intraoperative parathyroid hormone assay benefits surgery for primary hyperparathyroidism when preoperative localisation is negative or not performed.

INTRODUCTION: Parathyroid localisation is now routine before first-time surgery for patients with primary hyperparathyroidism (PHPT). The aim of this study was to investigate the contribution of intraoperative parathyroid hormone (PTH) (ioPTH) in patients in whom localisation was either not undertaken or negative for a tumour. METHODS: This was a retrospective study of patients undergoing first-time parathyroidectomy for PHPT in a regional endocrine centre. Data were collected prospectively (Microsoft Excel) and the all-Wales electronic patient record portal was used to retrieve missing data. Statistical analysis appropriate for nonparametric data was undertaken, with statistical significance reached when p<0.05. RESULTS: Between 1 July 2002 and 31 December 2022, 1,490 patients underwent a first-time parathyroidectomy for PHPT. Of this cohort, 1,133 patients had at least one positive imaging modality; the study group consisted of 343 patients that had negative imaging, and 13 that had no preoperative localisation. Patients with MEN-1 (n=26), an incorrect diagnosis (n=4), or less than six months follow-up (n=6) were excluded. Of the remaining 321, 106 patients underwent surgery without ioPTH (Group A), 215 cases with ioPTH (Group B). In Group B there were more women (170 female/45 male; 79% vs 67 female/37 male; 63% p=0.002, chi-squared), lower calcium (median [range] 2.77 [2.63-3.24] mmol/l; vs 2.85 [2.60-4.52] p=0.001) and lower PTH (12.0pmol/l [3.4-39.5] vs 14.4 [3.9-97.0] p=0.001) and smaller weights of resected tissue (320mg [50-9,000] vs 454 [46-8,280] p=0.02) (Student's t-test). The rate of multiple gland disease was similar (Group A 29%; Group B 27%). The rate of normocalcaemia at 6 months was significantly higher when ioPTH was used (Group B 202/215; 94% vs Group A 90/106; 85%) (p=0.014, chi-square test). The sensitivity and specificity of ioPTH was 98.5% [confidence interval (CI) 96.2-99.6] and 91.2% [80.7-97.0] (positive predictive value 99.9%, CI 93.6-100.0). CONCLUSION: Despite milder hyperparathyroidism and smaller tumour weight, the outcome in patients in whom ioPTH was used was superior, with failure rates 2.5-fold higher in the cohort where ioPTH was not utilised. The results of this study demonstrate that ioPTH is a valuable adjunct for the surgeon in cases where localisation has failed or not been undertaken.

A new approach for perioperative parathyroid hormone (PTH) measurement to establish cure in patients with primary hyperparathyroidism.

PURPOSE: In this study, we analyse the possibility to omit pre-incision PTH measurement since we routinely measure it at the time of pre-surgery ambulatory admission. METHODS: A total of 435 patients were enrolled. All patients with pHPT included underwent pre-surgical PTH level assessment as part of the pre-admission preparation to surgery. Intraoperative PTH was routinely assessed after induction of the anaesthesia (pre-incision PTH) and 15 min after resection of the enlarged gland(s) (post-excision PTH). Moreover, calcium and PTH levels were routinely assessed on the first postoperative day. Cure was defined as an intraoperative drop of > 50% or into normal range on first post-operative day. RESULTS: The median value of the preoperative and pre-incision PTH were both 127 pg/ml (p = ns). Thirty-two patients (7.3%) exhibited a not appropriate drop of post-excision PTH level. Nevertheless, nineteen of them (59.3%) showed a satisfying PTH drop on 1st POD. Ten patients (2.3%) experienced a persistent disease with six achieving cure through reoperation. Additionally, three patients (0.6%) showed normalization of calcium and PTH values during the follow-up. Three patients, apparently deemed cured after an adequate PTH-drop on the day of surgery, showed persistence. Cure rate at primary surgery was 98.4%. Accuracy of our simplified protocol is 99.3%. CONCLUSION: Pre-incision PTH is not superior to preoperative PTH blood test and can be omitted without compromising the sensitivity of cure prediction. One blood sample 15 min after resection, along with the postoperative PTH value on the day after surgery, is sufficient to predict the surgical outcome bearing the cost of a very low reoperation rate.

Severe Prolonged Hypocalcemia Following Four-Gland Parathyroidectomy in a Patient With Established Renal Failure.

Hypocalcemia after parathyroidectomy is a common complication. It is typically transient in patients with mild parathyroid-related bone disease. Distinguishing between hungry bone syndrome (HBS) and hypoparathyroidism following parathyroidectomy in established renal failure (ERF) patients presents a significant diagnostic challenge. This case study describes a 44-year-old male with severe hypocalcemia following a four-gland parathyroidectomy, highlighting the diagnostic considerations and management strategies.

Persistent primary hyperparathyroidism caused by an ectopic adenoma in the piriform sinus: case report and review of the literature.

Introduction: Primary hyperparathyroidism (PHPT) is a common endocrine disorder in which surgery is the only curative therapy. Ectopic parathyroid adenoma in the pyriform sinus resulting from a pathological migration of parathyroid glands along the embryological development is a rare cause of PHPT. We describe a case of a persistent primary hyperparathyroidism after previous unsuccessful surgery due to an ectopic parathyroid adenoma within the pyriform sinus and we review the previous reports on this issue. Case presentation: A 62-year-old woman was referred for persistent hypercalcemia following unsuccessful cervical exploratory surgery. Cervical ultrasound did not detect any parathyroid abnormalities. At variance, 99mTc-sestamibi SPECT/CT and CT scan of the neck identified a parathyroid adenoma in the left pyriform sinus, which was confirmed by endoscopy. The patient was successfully treated by transoral robotic resection and the pathology confirmed a parathyroid adenoma. Conclusions: The ectopic parathyroid adenoma in the pyriform sinus is so uncommon that only fourteen cases have been reported. However, the pyriform sinus should be considered a possible location of ectopic parathyroid glands, especially in the setting of persistent or recurrent PHPT after parathyroid surgery.

Parathyroidectomy restored bone mineral density in a neglected femoral neck fracture with renal osteodystrophy: A case report.

BACKGROUND: This case report contributes to the medical literature by highlighting the successful management of a neglected femoral neck fracture in a patient with renal osteodystrophy and secondary hyperparathyroidism (SHPTH) who was on dialysis due to end-stage renal disease (ESRD). It underscores the efficacy of parathyroidectomy (PTX) in restoring bone mineral density (BMD) and promoting fracture healing, addressing a significant complication in ESRD patients. CASE SUMMARY: A 36-year-old female with renal osteodystrophy and on dialysis due to ESRD presented with a history of left patellar tendon rupture and later, a right achilles tendon avulsion fracture. Persistent right hip pain led to the discovery of a neglected right femoral neck fracture, which was initially overlooked due to the patient's complex medical history. Two months post-achilles tendon repair, the patient underwent PTX to manage the refractory SHPTH. The postoperative course included rehabilitation and weight-bearing exercises. Remarkably, 2 years after osteosynthesis, radiographic assessments indicated a solid union of the periprothesis fracture and significant improvement in BMD, showcasing the efficacy of the treatment approach. CONCLUSION: PTX, combined with appropriate rehabilitation, is crucial for improving BMD and fracture healing in ESRD patients with SHPTH.

Trainee-initiated dictations of endocrine surgeries: Implications for education and reimbursement.

INTRODUCTION: Our university-based surgery department recently transitioned to attending-only authorship of operative reports. We performed a mixed-methods investigation to determine if trainee-initiated endocrine surgical reports were associated with under-coding of specific procedures. METHODS: Endocrine operations performed from July 2020 to June 2022 were identified from billing data. Pre- and post-policy RVU distributions and note modification history were reviewed to determine how often trainees captured billable differentiators over attending note modification. RESULTS: 714 operations and 1138 billed procedures were identified. Parathyroidectomy alone showed greater mean RVUs with attending-only reports attributable to attending practice change in coding for intraoperative parathyroid hormone monitoring. Trainees were more likely to miss coding modifier 22 but RVU losses were prevented by attending note modification. CONCLUSION: Trainee-initiated operative reports were not associated with RVU losses for endocrine operations compared to attending-only reports. Trainee dictation can be improved by emphasizing education on procedural billing differences and surgical reasoning.

Incidental parathyroidectomy after thyroid surgery and relationship with postoperative hypocalcemia: a single tertiary center analysis.

Incidental parathyroidectomy (IP) is a complication seen at varying rates after thyroid surgery, and its relationship with postoperative hypocalcemia has not been clarified. In this study, our goal was to identify the frequency and risk factors for IP in a large patient cohort and assess its correlation with postoperative hypocalcemia. A total of 4052 patients who underwent thyroid surgery between 2008 and 2020 were reviewed retrospectively. The patients were divided into two groups, the IP and non-IP groups, and compared in terms of demographics, surgical procedures, pathological diagnosis, and specimen weight. The relationships between IP and hypocalcemia were also evaluated. There were 587 (14.5%) IPs out of 4052 cases. In these patients, mostly one gland was removed (84.6%), and 23.2% of these glands were intrathyroidal. The rate of transient hypocalcemia was 39.9%, and that of permanent hypocalcemia was 1.7%. Female gender, malignancy, lower preoperative thyroid volume, presence of central lymph node dissection, lower specimen weight, presence of autotransplantation and capsule invasion in malignant cases were determined to be risk factors for IP. After excluding hemithyroidectomy and autotransplantation, transient and permanent hypocalcemia were found to be significantly higher in cases with IP (p < 0.001). Multivariate analysis showed that female sex, no multinodular goiter, central dissection, and low thyroid volume were risk-adjusted independent variables. Our findings highlight the significant role of IP in postoperative hypocalcemia. Given that most IPs are located in the perithyroidal region, precise surgical dissection is vital to preserve parathyroid gland function and prevent IP and subsequent hypocalcemia.

[Primary hyperparathyroidism: From diagnosis to treatment]. / L'hyperparathyroïdie primaire : du diagnostic à la prise en charge thérapeutique.

Primary hyperparathyroidism (PHPT) is the leading cause of hypercalcemia. It is secondary to hypersecretion of parathyroid hormone (PTH) by the parathyroid glands. Today, PHTP is asymptomatic in 80-90% of cases. Its repercussions are mainly renal (nephrolithiasis, nephrocalcinosis, decline in renal function) and skeletal (osteoporosis, fractures), and should be systematically investigated. Diagnosis is only biological, and in its classic form relies on the association of hypercalcemia, inappropriate PTH (normal or elevated) and hypercalciuria. Diagnosis of normocalcemic forms, where only PTH is elevated, requires elimination of secondary hyperparathyroidism and confirmation of elevated PTH on two consecutive samples, over a 3 to 6 months period. Imaging evaluation, which combines neck ultrasound with scintigraphy or 18F-choline PET/CT, is of interest only if surgery is indicated. Surgical management of the hyperfunctioning parathyroid gland(s) is the only curative treatment for HPTP. Medical management concerns patients for whom surgery is not indicated, who present a surgical contraindication or who refuse surgery. The diagnosis of HPTP warrants contact with an endocrinologist to ensure its management.

Parathyroid Cyst and Micropapillary Thyroid Carcinoma: A Case Study of Unexpected Concurrent Endocrine Pathologies.

Parathyroid cysts (PCs) are rare tumors that predominantly affect middle-aged women and are characterized by symptoms of hyperparathyroidism, including fatigue, bone pain, and gastrointestinal issues. Management typically involves surgical resection due to their potential to cause profound hyperparathyroidism and hypercalcemia. PCs occasionally coexist with thyroid malignancies, including micropapillary thyroid carcinoma (MPTC), although the pathophysiological link between PCs and thyroid cancers remains unclear. We present a case of a 62-year-old woman with symptomatic hypercalcemia and a large cystic mass adjacent to the left inferior thyroid pole, initially suspected to be a PC. Preoperative imaging, including an ultrasound (US) and sestamibi scan, guided surgical intervention, resulting in en bloc resection of the PC along with a left hemithyroidectomy. Pathological examination confirmed the presence of both a PC and MPTC, raising the question as to whether there is a possible correlation between primary hyperparathyroidism (PHPT) and thyroid malignancy. This report aims to highlight the current PC management protocol, underscore the importance of thorough diagnostic evaluation and surgical strategies in addressing concurrent parathyroid and thyroid pathologies, and explore potential pathophysiological connections between these conditions.