Impact of hyperparathyroidism on allograft histology and function after kidney transplantation: Rethinking its causal role in graft dysfunction.

INTRODUCTION: The causal relationship between hyperparathyroidism and kidney graft dysfunction remains inconclusive. Applying Bradford-Hill's temporality and consistency causation principles, we assessed the effect of parathyroid hormone (iPTH) on graft histology and eGFR trajectory on kidney transplant recipients (KTRs) with normal time-zero graft biopsies. METHODS: Retrospective cohort study evaluating the effect of hyperparathyroidism on interstitial fibrosis and tubular atrophy (IF/TA) development in 1232 graft biopsies. Pre-transplant hyperparathyroidism was categorized by KDIGO or KDOQI criteria, and post-transplant hyperparathyroidism by iPTH >1× and >2× the URL 1 year after transplantation. RESULTS: We included 325 KTRs (56% female, age 38 ± 13 years, follow-up 4.2 years [IQR: 2.7-5.8]). Based on pre-transplant iPTH levels, 26% and 66% exceeded the KDIGO and KDOQI targets, respectively. There were no significant differences in the development of >25% IF/TA between KTRs with pre-transplant iPTH levels above and within target range according to KDIGO (53% vs. 62%, P = .16, HR.94 [95% CI:.67-1.32]) and KDOQI (60% vs. 60%, P = 1.0, HR 1.19 [95% CI:.88-1.60]) criteria. Similarly, there were no differences when using 1 year post-transplant iPTH cut-offs > 88 pg/mL (58% vs. 64%, P = .33) and > 176 pg/mL (55% vs. 62%, P = .19). After adjusting for confounders, no significant differences were observed in eGFR trajectories among the iPTH strata. CONCLUSION: In young KTRs who received a healthy graft, no association was found between increased pre- and post-transplant iPTH levels and graft dysfunction, as assessed histologically and through eGFR trajectory. The concept of hyperparathyroidism as a risk factor for graft dysfunction in recipients at low risk requires reevaluation.

Insights into Hyperparathyroidism-Jaw Tumour Syndrome: From Endocrine Acumen to the Spectrum of CDC73 Gene and Parafibromin-Deficient Tumours.

A total of 1 out of 10 patients with primary hyperparathyroidism (PHP) presents an underlying genetic form, such as multiple endocrine neoplasia types 1, 2A, etc., as well as hyperparathyroidism-jaw tumour syndrome (HJT). We aimed to summarise the recent data, thus raising more awareness regarding HJT, from the clinical perspective of PHP in association with the challenges and pitfalls of CDC73 genetic testing and parafibromin staining. This narrative review included a sample-focused analysis from the past decade according to a PubMed search. We identified 17 original human studies (≥4 patients per article). The mean age at disease onset was between 20.8 and 39.5 years, while the largest study found that 71% of patients had HJT recognised before the age of 30. Males and females seemed to be equally affected, in contrast with sporadic PHP. PHP represented the central manifestation of HJT, occurring as the first manifestation in up to 85% of HJT cases. A biochemistry panel found a mean serum calcium level above the level of 12 mg/dL in PHP. PTH was elevated in HJT as well, with average values of at least 236.6 pg/mL. The most frequent pathological type in PHP was a parathyroid adenoma, but the incidence of a parathyroid carcinoma was much higher than in non-HJT cases (15% of all parathyroid tumours), with the diagnosis being established between the age of 15 and 37.5. In some families up to 85% of carriers suffered from a parathyroid carcinoma thus indicating that certain CDC73 pathogenic variants may harbour a higher risk. An important issue in HJT was represented by the parafibromin profile in the parathyroid tumours since in HJT both parathyroid adenomas and carcinomas might display a deficient immunoreactivity. Another frequent manifestation in HJT was ossifying fibromas of the jaw (affecting 5.4% to 50% of patients; the largest study found a prevalence of 15.4%). HJT was associated with a wide variety of kidney lesion (mostly: kidney cysts, with a prevalence of up to 75%, and renal tumours involved in 19% of patients). The risk of uterine lesions seemed increased in HJT, especially with concern to leiomyomas, adenofibromas, and adenomyosis. The underlying pathogenic mechanisms and the involvement of CDC73 pathogenic variants and parafibromin expression are yet to be explored. Currently, the heterogeneous expression of parafibromin status and, the wide spectrum of CDC73 mutations including the variety of clinical presentations in HJT, make it difficult to predict the phenotype based on the genotype. The central role of HJT-PHP is, however, the main clinical element, while the elevated risk of parathyroid carcinoma requires a special awareness.

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.

Rescate de un acceso vascular para hemodiálisis. A propósito de un caso / Recuing a vascular Access for hemodialysis. Report of a case

El mejor acceso vascular (AV) para hemodiálisis (HD) es, sin duda, la fístula arteriovenosa interna nativa (FAVI) ya que presenta más ventajas y menos complicaciones que otros accesos vasculares. Enfermería, gracias a los protocolos de vigilancia del AV, juega un papel fundamental en la detección temprana de las complicaciones que puedan llevar a la pérdida del mismo. Realizamos este estudio con dos objetivos: 1) Dar a conocer un caso clínico de una FAVI en el que aparecieron sucesivamente varias complicaciones. 2) Analizar la importancia que tiene la existencia de un equipo multidisciplinar para los accesos vasculares, tanto en la realización y seguimiento del mismo como en el tratamiento de las complicaciones que pudieran aparecer. Se estudia a un paciente varón con enfermedad renal crónica estadio V, portador de una FAVI radiocefálica derecha que, en una inspección rutinaria del AV cuando acude a la sesión de HD, enfermería detecta disminución de soplo y thrill apareciendo primero una trombosis, seguida de una estenosis tratada quirúrgicamente y finalmente una grave infección en la herida quirúrgica por un germen Gram negativo. A lo largo del estudio se van presentando las sucesivas complicaciones que surgieron y las estrategias desarrolladas por los miembros del equipo multidisciplinar: enfermeras, nefrólogos y cirujanos vasculares, entre otros, para solventarlas, lo cual finalmente se consiguió llegando a rescatar un acceso vascular que, a priori, dábamos por perdido (AU)

The best vascular access (VA) for hemodialysis (HD) is undoubtedly the native arteriovenous fistula (AVF) as presents more advantages and fewer complications than other vascular access. Nursing, using surveillance protocols of vascular, plays an essential role in the early detection of complications that might lead to their loss. We conducted this study with two objectives: 1) To present a clinical case of an AVF in which appeared on several complications. 2) Analyze the importance of the existence of a multidisciplinary team for vascular access in the implementation and monitoring of the same and in the treatment of possible complications. A male patient in stage five of CKD is studied, bearing a right radiocephalic AVF, which during a routine inspection of the AV when he came to the HD session, nursing detected decreased murmur and thrill appearing thrombosis first followed by stenosis treated surgically and finally a serious infection in the surgical wound by a Gram negative germs. During the study, subsequent complications that emerged and the strategies developed by the members of the multidisciplinary team are being presented: nurses, nephrologists and vascular surgeons, among others, to solve them, which finally got coming to rescue a vascular access a priori lost (AU)

Hipertensión arterial no controlable en el primer trimestre de la gestación. Hiperparatiroidismo primario, a propósito de un caso / Uncontrollable hypertension in the first trimester of pregnancy. Primary hyperparathyroidism; a case report

Mujer de 28 años. Sin antecedentes médico-quirúrgicos de interés. Gestación actual gemelar bicorial-biamniótica espontánea. Ingresa con 9 semanas por vómitos incoercibles con diagnóstico de hiperemesis gravídica. Las tensiones arteriales se mantienen elevadas. Se inicia estudio de enfermedad hipertensiva y tratamiento, sin mejoría. En las analíticas destacan una calcemia y PTH muy elevada con fosforemia baja. Se completa estudio con ecografía de cuello informada como presencia de lesión hipoecoica inferior al lóbulo tiroideo derecho sugestiva de adenoma paratiroideo. Se confirma diagnóstico de hipercalcemia severa secundaria a hiperparatiroidismo primario por adenoma de paratiroides. Se decide realizar paratiroidectomía en segundo trimestre, tras la cual se produce descenso de la calcemia y control de la tensión arterial y del resto de clínica. Aunque es la causa más frecuente de hipercalcemia en la población general, se trata de una enfermedad poco frecuente en mujeres en edad fértil. Su incidencia aproximada durante el embarazo es de 8/10.000. Durante el embarazo se produce una transferencia de calcio y fósforo materno al feto, lo que provoca la supresión de la secreción de PTH fetal y el incremento de los valores de calcitonina. Se asocia a una alta morbimortalidad materno-fetal, con riesgo de nefrolitiasis, hiperemesis, HTA, gran morbilidad con aumento de riesgo de preeclampsia y de afección renal. Como complicaciones obstétricas destacan el aumento del riesgo de aborto, amenaza de parto pretérmino y el desarrollo de fetos con retraso del crecimiento intrauterino. Entre las medidas conservadoras de tratamiento se recomienda mantener una buena hidratación oral, limitar la ingesta de calcio y tratar los síntomas asociados. La paratiroidectomía es el tratamiento definitivo y se debe realizar en el segundo trimestre

Spontaneous dichorionic-diamniotic twin pregnancy. Patient is admitted at 9weeks pregnant due to uncontrollable vomiting and is diagnosed with hyperemesis gravidarum. Blood pressure remains high. Study of hypertensive disease and treatment initiated without improvement. Blood tests showed a very high serum calcium and PTH with low phosphoremia. Study is completed with neck ultrasound revealing a lower hypoechoic lesion of the right thyroid lobe suggestive of parathyroid adenoma. Diagnosis of severe hypercalcemia secondary to primary hyperparathyroidism due to parathyroid adenoma was confirmed. It was decided to perform a parathyroidectomy in the second trimester after which a decrease in serum calcium, control blood pressure and other symptoms was found. Although it is the most common cause of hypercalcemia in the general population, it is a rare condition in women of childbearing age. Its approximate incidence during pregnancy is 8/10,000. During pregnancy, maternal calcium and phosphorus is transferred to the fetus, which results in suppression of fetal PTH secretion and increased fetal calcitonin values. It is associated with high maternal and fetal morbidity and mortality and risk of nephrolithiasis, hyperemesis, hypertension, high morbidity with increased risk of preeclampsia and kidney disease. In the fetus, there is an increased risk of spontaneous abortion, intrauterine growth retardation and preterm birth. Among conservative treatment measures, it is recommended to maintain good oral hydration, limit calcium intake and treat associated symptoms. Parathyroidectomy is the definitive treatment and should be performed in the second trimester

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.

Hybrid-fusion SPECT/CT systems in parathyroid adenoma: Technological improvements and added clinical diagnostic value / Sistemas de imagen híbrida de fusión SPECT/TC en adenoma de paratiroides: avances tecnológicos y valor añadido en el diagnóstico clínico

Nuclear medicine traditionally employs planar and single photon emission computed tomography (SPECT) imaging techniques to depict the biodistribution of radiotracers for the diagnostic investigation of a range of disorders of endocrine gland function. The usefulness of combining functional information with anatomy derived from computed tomography (CT), magnetic resonance imaging (MRI), and high resolution ultrasound (US), has long been appreciated, either using visual side-by-side correlation, or software-based co-registration. The emergence of hybrid SPECT/CT camera technology now allows the simultaneous acquisition of combined multi-modality imaging, with seamless fusion of 3D volume datasets. Thus, it is not surprising that there is growing literature describing the many advantages that contemporary SPECT/CT technology brings to radionuclide investigation of endocrine disorders, showing potential advantages for the pre-operative locating of the parathyroid adenoma using a minimally invasive surgical approach, especially in the presence of ectopic glands and in multiglandular disease. In conclusion, hybrid SPECT/CT imaging has become an essential tool to ensure the most accurate diagnostic in the management of patients with hyperparathyroidism (AU)

La medicina nuclear emplea tradicionalmente imágenes estáticas 2D, aunque en los últimos años se ha incrementado la imagen 3D tomográfica SPECT. Estas técnicas de imagen permiten la observación de la biodistribución de los radiotrazadores, destinados a la investigación diagnóstica de trastornos endocrinos que cursan con afectación glandular. La utilidad de combinar la información funcional con la anatómica tomando como referencia la tomografía computarizada (TC), la resonancia magnética (RM) y los ultrasonidos de alta resolución (US) ha sido estudiada mediante una correlación visual primero y posteriormente con el soporte de un software de co-registro de imágenes, sin obtener resultados satisfactorios. Los equipos híbridos SPECT/TC permiten la adquisición simultánea de diferentes modalidades de imagen, consiguiendo una fusión adecuada de ellas y su posterior reconstrucción volumétrica. Así pues, no es de extrañar que cada vez observemos mayor evidencia en la literatura que describe las múltiples ventajas de la tecnología SPECT/TC en la localización preoperatoria del adenoma de paratiroides con cirugía mínimamente invasiva, especialmente en presencia de patología multiglandular o de glándulas ectópicas. En resumen, la imagen híbrida se ha convertido en una herramienta esencial que garantiza la mayor exactitud diagnóstica en el manejo de pacientes con hiperparatiroidismo (AU)

Adenoma de paratireóide diagnosticado por punção aspirativa por agulha fina: relato de caso / Parathyroid adenoma diagnosed by fine needle aspiration cytology: a case report

Os autores relatam o caso de uma paciente com hiperparatireoidismo primário causado por adenoma de paratireóide diagnosticado através de punção aspirativa por agulha fina (PAAF) no pré-operatório. A paratireóide aumentada foi visualizada pela ultra-sonografia (US) e submetida à PAAF, que foi compatível com adenoma de paratireóide. Realizou-se a remoção cirúrgica do adenoma e o histopatológico resultou concordante com a citologia. Este relato destaca a importância da localização e do diagnóstico citológico pré-operatório das lesões de paratireóide para proporcionar uma abordagem cirúrgica menos agressiva.

The authors report a patients case with primary hyperparathyroidism caused by parathyroid adenoma that was diagnosed by fine needle aspiration cytology (FNAC) in the preoperative. The increased parathyroid was visualized by the ultrasonography and submitted to FNAC that was compatible with parathyroid adenoma. The surgical removal of adenoma was accomplished and the histopathologic was concordant with the cytology. This report detaches the importance of the location and preoperative cytological diagnosis of the parathyroid lesions in providing a less aggressive surgical approach.

Quiste paratiroideo e hiperparatiroidismo / Parathhyroid cyst and hyperparathyroidism

No disponible

Análisis de nuestros resultados actuales en el tratamiento quirúrgico del hiperparatiroidismo (1990-2005) / Analysis of our recent results in the surgical treatment of the hyperparathyroidism (1990-2005)

Objetivo: Presentar nuestra experiencia actualizada (1990-2005) en el tratamiento quirúrgico del hiperparatiroidismo. Material y métodos: Hasta la fecha llevamos intervenidos 153 pacientes (41 varones y 112 mujeres) con edades comprendidas entre los 14 y 79 años. Se estudiaron las manifestaciones clínicas referidas por los mismos, pruebas de imagen preoperatorias, tipo de hiperparatiroidismo, cirugía respectiva, resultado o diagnóstico final anatomopatológico y complicaciones postoperatorias. Resultados: Los adenomas de paratiroides representaron el 69,73% por un 26,31% de hiperplasias. En 6 casos las glándulas remitidas fueron informadas como normales. Destacamos el predominio de adenomas localizados en paratiroides inferiores sobre las superiores (relación > 5,5:1). Entre las complicaciones obtuvimos 35 hipocalcemias postquirúrgicas (31 transitorias y 4 permanentes), 1 caso de parálisis recurrencial sobre 233 nervios expuestos, 5 hemorragias que precisaron reintervención y 4 persistencias de hipercalcemia. Globalmente conseguimos una reducción de calcio y PTH con mejoría clínica en más del 96% de los pacientes operados. Discusión-conclusión: La cirugía del hiperparatiroidismo proporciona muy buenos resultados en general como constatamos en nuestro trabajo y en otras series publicadas

Objective: To report our recent experience (1990- 2005) in the surgical treatment of hyperparathyroidism. Material and method: Up to now we have operated 153 patients (41 male and 112 female) with ages between 14 and 79 years old studying the clinical symptoms referred by them, preoperative imaging tests, type of hyperparathyroidism, its respective surgery, result or final anatomopathological diagnosis and postoperative complications. Results: Parathyroid adenomas represented a 69.73% while the hyperplasias were about 26.31%. In 6 cases the glands removed were informed as normal. It stands out that the most rare adenomas were located in lower parathyroids with a relation > 5,5:1 respect to the upper ones. Among the complications we obtained 35 postoperative hypocalcemias (31 transient and 4 persistent), one case of recurrent nerve palsy after exposure of 233 nerves, 5 haemorrhages that required reintervention and 4 persistences of hypercalcemia. Globally we were able to reduce the calcium and PTH serum levels with clinical improvement in more than 96% of the operated patients. Discussion-conclusion: The surgery for hyperparathyroidism provides very good results in general as we stated in other published series

Reintervención por adenoma ectópico de paratiroides con extirpación previa de lipotimoma. Importancia de la PTH en intraoperatoria / Reoperation because of ectopic parathyroid adenoma with previous removal of lipotimoma. Importance of intraoperative PTH

En ocasiones la cirugía del hiperparatiroidismo no resulta sencilla y el equipo quirúrgico se encuentra con dificultades para localizar la glándula o glándulas patológicas. Presentamos un caso de hiperparatiroidismo primario debido a adenoma de paratiroides en situación ectópica que requirió dos intervenciones. En la primera se extirpó lo que parecía un adenoma pero resultó ser un lipotimoma. En la reintervención efectuada una semana después, contando entonces con la determinación de PTH intraoperatoria rápida o turbo y una gammagrafía digital previa, se consiguió extirpar un adenoma confirmado histológicamente, de 3,5 cm de diámetro localizado en profundidad al lóbulo tiroideo derecho y que descendía hacia el estrecho mediastínico superior. La evolución postoperatoria de la paciente fue satisfactoria y no se registraron complicaciones

Sometimes the surgery of hyperparathyroidism is not easy and the surgical team find difficulties to locate the pathological gland or glands. We report a case of primary hyperparathyroidism due to an ectopic parathyroid adenoma which required two interventions. First we removed what it seems an adenoma but resulted to be a lipotimoma. In the reintervention practiced one week later, having then the rapid or turbo intraoperative PTH and previous digital scintigraphy, it was possible to remove an adenoma histologically confirmed, with 3,5 cm diameter located in depth to right thyroid lobe towards the superior mediastinal straits. The postoperative evolution of the patient was satisfactory and no complications were registered

Múltiple tumores pardos en paciente con hiperparatiroidismo terciario / Múltiple brown tumours in a patient with tertiary hyperparathiroidism

Describimos el caso de una mujer de 49 años con insuficiencia renal crónica e hiperparatiroidismo secundario que no cedió tras transplante y se convirtió en una forma autónoma (hiperparatiroidismo terciario). Las pruebas de imagen revelaron la presencia de múltiples tumores pardos en huesos pélvicos y tibia. La paciente fue intervenida mediante paratiroidectomía resecando un adenoma inferior izquierdo confirmado posteriormente en el estudio histológico. Tras la cirugía mejoraron las manifestaciones osteoarticulares y desapareció la litiasis renal. No se registraron complicaciones posoperatorias como hipocalcemia o parálisis recurrencial aunque el Servicio de Nefrología tuvo que controlar la función renal

We describe the case of a 49-year-old female with chronic renal failure and secondary hyperparathyroidism that not dissapeared after kidney transplant and turned into an autonomous form (tertiary hyperparathyroidism). The xRays and CT showed the presence of multiple brown tumors in iliac bones and tibia. We performed a parathyroidectomy removing a lower left adenoma confirmed in the histological exam the renal. After the surgery the osteoarticular manifestations improved and lithiasis dissapeared. There were not any postoperative complications such as hypocalcemia or recurrential palsy although Nephrology Department had to control her renal function

Condrocalcinosis (pseudogota) después de tratamiento quirúrgico de hiperparatiroidismo. Presentación de un caso y revisión de la literatura / Chondrocalcinosis (pseudogout) after surgical treatment of primary hyperparathyroidism. Report of a case and review of the literature

Se presenta el caso de una paciente de 61 años que desarrolló una artritis aguda después de la realización de una paratiroidectomía por hiperparatiroidismo primario. El diagnóstico de condrocalcinosis o pseudogota se estableció por la presentación clínica, hallazgos radiológicos y la demostración de los cristales de pirofosfato cálcico dihidratado en líquido sinovial. El brusco descenso de los niveles de calcio tras la extirpación del adenoma puede precipitar estos episodios agudos inflamatorio s articulares no tan infrecuente s como constatamos tras realizar una revisión bibliográfica sobre esta asociación

We are reporting the case of a 61 years-old female who developed an acute arthritis following parathyroidectomy because a primary hyperparathyroidism. The diagnosis of chondrocalcinosis or pseudogout was made by the clínical presentation, radiologic findings and demonstration of synovial fluid crystals of calcium pyrophosphate dihydrate. Rapid drops in serum calcium levels after removal of the adenoma may precipitate these acute articular inflammatory attacks that are not so uncommon as we can recognize if a biblíographic review about that association is performed

Utilidad de la tomografía axial computerizada y la resonancia mágnetica nuclear en el diagnóstico preoperatorio del hiperparatiroidismo / Usefulness of computed tomography and magnetic resonance in the preoperative diagnosis for hyperparathyroidism

Las pruebas de imagen preoperatorias más solicitadas actualmente en la cirugía del hiperparatiroidismo son la ecografia y la gammagrafia con Tc-99m sestamibi. El objetivo de nuestro trabajo es conocer si la Tomografia Axial Computerizada (TAC) y la Resonancia Magnética Nuclear (RMN) son útiles como estudio de localización y en qué casos estaría más justificado solicitar estas técnicas radiológicas. Para ello presentamos nuestros resultados con un total de 29 pacientes diagnosticados de hiperparatiroidimo (26 primarios y 3 secundarios) que posteriormente fueron intervenidos por nuestro Servicio de ORL. En 20 de ellos se pidió un TAC cervical antes de la paratiroidectomía y en los 9 restantes una RMN con sensibilidades respectivas del 65% y 88,9%. Creemos que ambas pruebas no deben solicitarse de rutina, pero sí pueden suponer una ayuda en los casos en los que la eco y gammagrafía no son capaces de mostrar el posible adenoma o hiperplasia, particularmente en hiperparatiroidismos recurrentes, reintervenciones o sospecha de paratiroides en localización atípica

Sonnography and Tc-99m sestamibi scintigraphy are the most requested preoperative imaging tests nowdays in the surgery ofhyperparathyroidism. The aim of OUT article is to know ifComputerized Tomography (CT) and Magnetic Resonance Imaging (MRI) are useful as a location study and in which cases it would be more justified to ask these radiologic techniques. For that we report OUT results with 29 patients at all diagnosed as hyperparathyroidism (26 primary forms and 3 secondary ones) and operated by our E.N.T. Department later. On 20 ofthem a cervical CT was asked before the parathyroidectomy and on the rest 9, a MRI with sensitivities of 65% and 88,9% respectively. We think both complementary explorations must not be solicited by routine but they can represent a help in the cases in that sonnography and scintigraphy are not able to show the possible adenoma or hiperplasia, particularly in recurrent hyperparathyroidisms, reinterventions or suspect of parathyroid glands in an atypical location

Asociación entre hiperparatiroidismo primario y enfermedad de Paget / Association between primary hyperparathyroidism and Paget´s disease- Report of a case

Aunque la asociación entre el hiperparatiroidismo y la enfermedad de Paget es conocida, en la práctica clínica ocurre muy raramente. Presentamos el caso de una mujer de 68 años que estaba diagnosticada de dicha enfermedad hacía más de 5 años y que posteriormente experimentó un aumento de la PTH e hiperca1cemia junto con otras alteraciones bioquímicas que hicieron sospechar un hiperparatiroidismo primario. Además de manifestaciones osteoarticulares, clínicamente la paciente sufría litiasis renal de repetición. Fue sometida a resección de un adenoma de 1,5 cm localizado en la glándula paratiroides inferior derecha y la evolución fue satisfactoria sin complicaciones

Although the association between hyperparathyroidism and Paget' s disease is known, in the clinical practice occurs very rarely. We report the case of a 68 years old female who was diagnosed as such disease more than 5 years ago and later she got an increment of PTH levels and hypercalcemia joint to other biochemical disorders that made to suspect a primary hyperparathyroidism. Besides the osteoarticular manifestations, clinically the patient suffered recurrent kidney lithiasis. She was operated by remo val of one adenoma (1,5 cm) located in lower right parathyroid gland and her evolution was satisfactory without complications

Tumor pardo óseo como primera manifestación de hiperparatiroidismo primario / Brown bone tumour as the first manifestation of primary hyperparathyroidism

Presentamos el caso clínico de una mujer de 26 años que refería tumoración mentoniana de 2 años de evolución con hipercalcemia (11,8 mg/dl) y PTH (paratohormona) de 761 pg/ml. Se realizó TAC mandibular y RMN, así como biopsia del tumor con exéresis del mismo por parte del Servicio de Máxilo-Facial. Nuestro Servicio de O.R.L. solicitó una gammagrafía (Tc99 S-mibi) y TAC cérvicotorácico que informaban de la presencia de una lesión que, tras cirugía y estudio AP, resultó ser un adenoma de paratiroides inferior derecha. El hiperparatiroidismo primario que presentaba la paciente era el estímulo principal del tumor pardo, formado por células gigantes multinucleadas y macrófagos, siendo éste la primera manifestación del desorden metabólico. Esta presentación del hiperparatiroidismo es muy poco frecuente en la clínica. Realizamos una revisión de la literatura y establecemos el diagnóstico diferencial para tal patología. (AU)

We report a clinical case of a 26 years old female who had a 2 years evolution chin tumour with hypercalcemia (11.8 mg/dl) and PTH (paratohormone) of 761 pg/ml. She underwent a CT scan and MRI of the mandible, as well as a biopsy followed by excision of the tumour by the maxilofacial surgeons. Our ENT Department asked for a Scintigraphy (Tc99s-mibi) and thoracic-cervical CT, which showed a lesion that turned out to be an adenoma of the lower right parathyroid gland after surgery and pathological examination. The patient suffered a Primary hyperparathyroidism that was the main stimulus for the Brown Tumour made up by macrophagos and multinuclear giant cells, being this the first manifestation of the metabolic disorder. This form of hyperparathyroidism is very rare in the clinic. We do a literature review to establish the differential diagnosis for such pathology (AU)

Hiperparatiroidismo / Hyperparathyroidism

El calcio es esencial para varias funciones del cuerpo, incluyendo la contracción muscular, la conducción nerviosa y el funcionamiento apropiado de muchas enzimas. La mayor parte del calcio del cuerpo se almacena en los huesos, pero también se encuentra en las células y en la sangre. El organismo controla con "toda precisión" la cantidad de calcio tanto en la célula como en la sangre. Para mantener este equilibrio entra en competencia la hormona para tiroidea, secretada por las glándulas paratiroidea. La actividad de las glándulas paratiroideas está controlada por el nivel de calcio libre (ionizado) de la sangre. El descenso de los niveles de este calcio estimula la síntesis y secreción de hormonas paratiroideas, si la cantidad de calcio libre en sangre aumenta, estamos frente a una alteración metabólica "La Hipercalcemia" la cual consiste en una concentración elevada de calcio en sangre superior a 10.5 miligramos por decilitro de sangre, la que puede ser causada por aumento en la ingestión de calcio, pero la causa más común de la hipercalcemia es el "Hiperparatiroidismo", el cual se debe a la hipersecreción de hormonas paratiroideas. Esta alteración puede deberse a un adenoma paratiroide (80%). Hiperplasia primaria (15%). Carcinoma paratiroide (5%). Fenómeno secundario típico de los pacientes con insuficiencia renal crónica. El hiperparatiroidismo puede manifestarse en la cavidad bucal en forma de hiperplasia gingival y lesiones osteolíticas de los maxilares (Tumores pardos) que son asintomáticas. El objetivo de este trabajo es realizar una revisión bibliográfica actualizada sobre esta patología y resaltar la importancia que representan las manifestaciones orales de esta patología sistémica para el odontólogo en general, especialmente para el cirujano oral y maxilofacial.

Afecçöes cirurgicas das glandulas paratiroides / Surgical affections of parathyroid glands

O autor faz uma revisao da literatura sobre o hiperparatiroidismo primario, apresenta um caso de carcinoma funcionante da paratiroide inferior direita e descreve a tecnica cirugica

Surgical management of hyperparathyroidism. A 24 years experience

Our 24 years experience in the surgical treatment of 130 patients with primary hyperparathyroidism was presented. A single adenoma of the parathyroid glands was the predominant lesion. The lower parathyroid glands were more frequently the site of the adenoma, with the right lower gland presenting the highest incidence. The incidence of hyperplasia and carcinoma is similar to the reported literature. The offending glands were identified in the vast majority of the patients. The number of complications is significantly low with a zero surgical mortality. The utilization of preoperative localizing test is not recommended for the initial neck exploration. Satisfactory results can be obtained with a minimal work up