Treatment of parathormone-dependent hypercalcaemia in the third-trimester of pregnancy.

Not required for Clinical Vignette.

Acute pancreatitis associated with primary hyperparathyroidism during pregnancy.

Not required for Clinical Vignette.

Parathormone concentration in the fluid of fine-needle parathyroid biopsy for assessing the effectiveness of surgical treatment of patients with primary hyperparathyroidism.

INTRODUCTION: The aim of the work was to evaluate the usefulness of intraoperative determination of parathyroid hormone (PTH) concentration in the fluid of fine-needle biopsy lesions of pathologically parathyroid glands for their identification and evaluation of the effectiveness of surgical treatment of primary hyperparathyroidism (PHP). MATERIAL AND METHODS: The study group comprised 75 patients: 65 women and 10 men, aged 33-78 years (mean 57.5), operated in the years 2019-2020 due to PHP. Seventy-nine biopsies of fine-needle aspiration lesions were assessed intraoperatively as pathological parathyroid glands were collected, and the concentration of PTH was determined in their lavage fluid. The results were compared with a control group of 20 patients operated at that time for various forms of goitre, without concomitant parathyroid disease. RESULTS: In 79 biopsies, the presence of the parathyroid gland was confirmed 72 times. The concentration of PTH in the biopsy fluid exceeded the value of 5000 pg/mL 70 times, 1 was 3733 pg/mL, and 1 was 1985 pg/mL. Seven times (8.9%), the biopsy was for a colloidal nodule instead of the parathyroid gland. The concentration of PTH in the fluids of these biopsies was low and ranged from 5.3 to 500 pg/mL. In the control group, the concentration of PTH in postoperative thyroid biopsies was low and did not exceed the reference value range of up to 64 pg/mL. Comparison of the results of the study group with the control group shows significantly higher PTH values in parathyroid biopsies compared to biopsies of thyroid specimens (p = 0.017), with a sensitivity of 100% and a specificity of nearly 93%. CONCLUSIONS: Intraoperative determination of PTH concentration in the fluid of fine-needle biopsy lesions with diseased parathyroid glands allows for their identification and evaluation of the effectiveness of surgical treatment of PHP. Testing the concentration of PTH in the biopsy fluid of dissected parathyroid glands is characterized by high sensitivity and specificity of the method. The value of PTH concentration in fluid from parathyroid biopsies does not depend on the cause of PHP.

Multiglandular Parathyroid Disease.

INTRODUCTION: Multiglandular parathyroid disease (MGD) is an uncommon cause of primary hyperparathyroidism (pHPT) and has been reported in the literature in 8-33% of patients with pHPT. The aim of our study was to review the clinical characteristics and management of MGD and evaluation of surgical treatment failures. METHODS: We performed a retrospective study of 163 patients with pHPT undergoing parathyroidectomy (PTX) at the Department of General and Endocrine Surgery between 1983 and 2018. All these patients were diagnosed with MGD. This group of patients was compared with a group of 856 patients with solitary disease operated for pHPT in the same period. RESULTS: Among 163 patients-127 (79%) of them had two lesions, 28 (16%) had three, and 8 (5%) four. They were prevalently women over the age of 50. The diagnosis was based on PTH and ionized calcium studies and used sestamibi technetium-99m scintigraphy (MIBI) as well for us. Treatment was surgical. CONCLUSIONS: Parathyroidectomy (PTX) for multiglandular parathyroid disease (MGD) is associated with a higher operative risk of failure compared to solitary disease. Preoperative diagnosis and localization of the parathyroid glands is an extremely important element of treatment. Diagnosis is based on PTH and calcium levels. Ultrasonography (USG), MRI, and scintigraphy are very helpful in diagnosis. Mediastinal multiglandular parathyroid disease (MGD) is associated with increased surgical treatment failures. The treatment is surgical and consists of the removal of the masses or complete parathyroidectomy. Based on this study, we support the existence of multiple adenomas and advocate the removal of only macroscopically enlarged parathyroid glands in patients with primary hyperparathyroidism.

Diagnosis and treatment of thyroid cancer in adult patients - Recommendations of Polish Scientific Societies and the National Oncological Strategy. 2022 Update [Diagnostyka i leczenie raka tarczycy u chorych doroslych - Rekomendacje Polskich Towarzystw Naukowych oraz Narodowej Strategii Onkologicznej. Aktualizacja na rok 2022].

The guidelines Thyroid Cancer 2022 are prepared based on previous Polish recommendations updated in 2018. They consider international guidelines - American Thyroid Association (ATA) 2015 and National Comprehensive Cancer Network (NCCN); however, they are adapted according to the ADAPTE process. The strength of the recommendations and the quality of the scientific evidence are assessed according to the GRADE system and the ATA 2015 and NCCN recommendations. The core of the changes made in the Polish recommendations is the inclusion of international guidelines and the results of those scientific studies that have already proven themselves prospectively. These extensions allow de-escalation of the therapeutic management in low-risk thyroid carcinoma, i.e., enabling active surveillance in papillary microcarcinoma to be chosen alternatively to minimally invasive techniques after agreeing on such management with the patient. Further extensions allow the use of thyroid lobectomy with the isthmus (hemithyroidectomy) in low-risk cancer up to 2 cm in diameter, modification of the indications for postoperative radioiodine treatment toward personalized approach, and clarification of the criteria used during postoperative L-thyroxine treatment. At the same time, the criteria for the preoperative differential diagnosis of nodular goiter in terms of ultrasonography and fine-needle aspiration biopsy have been clarified, and the rules for the histopathological examination of postoperative thyroid material have been updated. New, updated rules for monitoring patients after treatment are also presented. The updated recommendations focus on ensuring the best possible quality of life after thyroid cancer treatment while maintaining the good efficacy of this treatment.

Parathyroid carcinoma - a study of 29 cases.

INTRODUCTION: Parathyroid carcinoma is a rare condition and accounts for < 1% of cases of sporadic primary hyperparathyroidism. It accounts for 0.005% of all cancers. Often the differentiation between adenoma and carcinoma is challenging and requires multidisciplinary cooperation. Complete surgical resection is the treatment of choice. We present a retrospective analysis of 29 patients who were surgically treated for parathyroid cancer. MATERIAL AND METHODS: Between the years 1983 and 2018, 71 (7.0%) patients were treated for suspicion of parathyroid cancer among a group of 1019 operated for primary hyperparathyroidism. RESULTS: We confirmed the diagnosis of parathyroid cancer in 29 (2.8%) patients, 12 men and 17 women, aged 27 to 77 years, mean 55.1 years. That constituted 43.9% of the 71 patients with initial suspicion of cancer diagnosis. All operated patients were under long-term observation. CONCLUSIONS: A diagnosis of parathyroid carcinoma should always be considered during surgery in patients diagnosed with primary hyperparathyroidism, especially in patients with severe hypercalcaemia, significantly enlarged neck circumference, and concomitant diseases of the renal and skeletal system. Parathyroid carcinoma is rarely definitively diagnosed preoperatively or even intraoperatively, and the final diagnosis can be made exclusively after operation. The optimal treatment is a complete surgical resection at a reference centre - specialized in parathyroid surgery - to improve outcomes and provide the best chance of recovery.

Flow cytometric DNA analysis of parathyroid benign lesions.

INTRODUCTION: It is difficult to differentiate benign and malignant lesions just by histopathological evaluation due to lack of clear criteria of diagnosis. Moreover, the group of benign pathologies of parathyroids is not homogenous, and recurrence of symptoms of hyperparathyroidism after surgical management was also noted in this group. This complication is not always due to inappropriate surgical technique. The goal of this work was to find the relationship between cellular ploidy and proliferative activity of adenomas and hyperplasia of parathyroids and preoperative levels of calcium and parathormone in the serum of patients surgically treated for primary hyperparathyroidism. MATERIAL AND METHODS: A total of 98 parathyroid glands were tested, of which 81 (82.7%) were from female patients and 17 (17.3%) from male; the age of the patients was from 22 to 82 years, with an average of 58 years. RESULTS: In resected glands pathological evaluation showed the following results: in 53 (54.1%) adenoma was present, and in 45 (45.9%) there was hyperplasia. Sixty-seven of the samples (68.4%) were characterised as diploid and 31 (31.6%) as aneuploid. There is important positive correlation (r = 0.34595; p = 0.011) between the percentage of S-phase cells (% SPF) and calcium levels measured prior to surgical resection of adenoma. The further analysis of patients with adenoma characterised by aneuploidy proved a statistically valid, positive correlation between %SPF and ionised calcium levels in blood serum of patients both before (r = 0.7189; p = 0.003) and after the surgical treatment (r = 0.6313; p = 0.012). CONCLUSIONS: 1. Benign lesions of parathyroid with ploidy indicates their heterogeneity. 2. In aneuploid benign adenomas of parathyroid glands an increased percentage of cells in S phase (% SPF) correlates with a high level of calcium in serum pre- and post-parathyroidectomy.

Surgical Management of Primary Hyperparathyroidism-Clinicopathologic Study of 1019 Cases from a Single Institution.

BACKGROUND: Primary hyperparathyroidism (pHPT) is an endocrine disorder characterized by hypercalcemia and caused by the presence of disordered parathyroid glands. Parathyroidectomy is the only curative therapy for pHPT, but despite its high cure rate of 95-98%, there are still cases where hypercalcemia persists after this surgical procedure. The aim of this study was to present the results of a surgical treatment of patients due to primary hyperparathyroidism and failures related to the thoracic location of the affected glands. METHODS: We present a retrospective analysis of 1019 patients who underwent parathyroidectomy in our department in the period 1983-2018. RESULTS: Among the group of 1019 operated-on patients, treatment failed in 19 cases (1.9%). In 16 (84.2%) of them, the repeated operation was successful. In total, 1016 patients returned to normocalcemia. CONCLUSIONS: Our results confirm that parathyreoidectomy is the treatment of choice for patients with primary hyperparathyroidism. The ectopic position of the parathyroid gland in the mediastinum is associated with an increased risk of surgical failure. Most parathyroid lesions in the mediastinum can be safely removed from the cervical access.

Primary hyperparathyroidism.

Primary hyperparathyroidism is an endocrine disorder that results in overproduction of parathyroid hormone by overactivated parathyroid gland leading to a significant rise in blood serum calcium. It results in hypercalcaemia, which has a significant impact mainly on the kidneys and bones and results in a variety of signs and symptoms. Primary hyperparathyroidism should be treated because, if left without any therapy, it can lead even to death. Surgery is considered as the best and only successful therapy, with very low risk of recurrence and relatively low complication rate. The aim of this review is to present clinical basis, aetiology, diagnostic possibilities, and treatment opportunities.

Surgical treatment of patients with primary hyperparathyroidism with a risk of hypercalcaemic crisis.

INTRODUCTION: The objective of the work was to evaluate the effectiveness of surgical treatment in patients with a high risk of hypercalcaemic crisis due to primary hyperparathyroidism (PHPT) and to determine the best time to undergo surgery. MATERIAL AND METHODS AND RESULTS: Between 2010 and 2019, 627 patients underwent surgery due to PHPT. Sixty-two patients (9.9%) (47 women and 15 men, aged 28-79 years, average 53.7 years) faced the threat of a parathyroid crisis. In these patients, the average parathyroid hormone (PTH) levels were 774.02 pg/mL (95% CI: 203-1246 pg/mL) and ionised calcium (iCa2+) 1.91 mmol/L (95% CI: 1.70-2.2 mmol/L). The PTH postoperative concentration averaged at 37.86 pg/mL (95% CI: 9.91-42.7 pg/mL) and iCa2 + 1.11 mmol/L (95% CI: 1.07-1.21 mmol/L). Bilateral neck exploration was performed in all patients with the removal of the affected parathyroid gland and biopsies of other parts. Histopathological examination revealed adenoma in 42 cases (67.7%), hyperplasia in 16 (25.7%), and parathyroid cancer in four of the patients (6.6%). Comparison of tests before and after surgery showed a statistically significant decrease in PTH (p < 0.001) and iCa (p < 0.001) in blood serum. CONCLUSIONS: A developing hypercalcaemic crisis in the course of hyperparathyroidism is an indication for preoperative intensive medical therapy, along with urgent surgical intervention and removal of diseased parathyroid glands. This type of surgery should be performed as soon as possible, even if there are no imaging tests, only based on an assessment of the general condition of the patient and their serum calcium levels.

Depressive and anxiety disorders in patients with primary hyperparathyroidism. / Zaburzenia depresyjne i lekowe u chorych z pierwotna nadczynnoscia przytarczyc.

OBJECTIVES: The objective of the study was to evaluate the prevalence and severity of anxiety and depression in patients with primary hyperparathyroidism (PHPT), and to determine a relationship between the severity of these disorders and the serum calcium ion and parathyroid hormone level, as well as to evaluate the usefulness of self-rating scales in screening for depressive disorders in PHPT patients. METHODS: Using the 17-item Hamilton Depression Rating Scale (HAM-D), Beck Depression Inventory-II (BDI-II) and Hospital Anxiety and Depression Scale (HADS), study was performed on a group of 101 patients with PHPT. A control group included 50 patients diagnosed with non-toxic thyroid goiter. RESULTS: The HAM-D indicated higher prevalence and severity of depressive symptoms in the whole population of patients and in women with PHPT. Such a relationship was not observed in men. The BDI-II indicated higher prevalence and severity of depressive symptoms in the whole population of patients and in women with PHPT. Such a relationship was not observed in men. The HADS did not show significant differences in the prevalence of depressive and anxiety symptoms between the study and control groups in the whole population and after taking into account the gender division. CONCLUSIONS: A relationship between PHPT and depression was confirmed. Such a relationship was not confirmed for anxiety. A relationship between the severity of depression and the serum calcium ion and parathyroid hormone level was also not confirmed. A statistically significant negative correlation between the severity of anxiety and the serum calcium ion level in the whole population of patients, and an additional positive correlation between the serum parathyroid hormone level and the severity of anxiety in women were confirmed. Self-rating tests are not sufficient for screening for depressive disorders in PHPT patients.

Analysis of Diagnostic Methods for Focal Lesions in Breast Glands with Use of Open Surgical Biopsies and Core-Needle Biopsies in Poland.

BACKGROUND Numerous studies confirm the benefits of using core-needle biopsy (CNB) for diagnosing patients with suspected breast cancer, thus reducing the costs and the stress, and allowing optimum treatment planning. The present study examined the number of patients in Poland who had been diagnosed with breast cancer through inpatient open surgical biopsy (OSB) and CNB by province. MATERIAL AND METHODS This retrospective study used a health needs map to identify patients in 2014 and partially in 2015 who had had OSB or CNB of the breast performed on an inpatient basis due to benign breast lesions and whose diagnosis had been changed from benign to malignant. RESULTS Among the total number of hospitalizations (13 718 cases with OSB) due to benign lesions of the breast, 1506 patients had their diagnosis changed to malignant, constituting 8.59% of new breast cancer diagnoses across the country. The resulting diagnosis change from benign to malignant varied significantly across provinces, from 5.3% to 23.4%. Among the total of 7205 hospitalizations in 2014 with CNB performed using different methods, there were 1574 malignancies, amounting to 8.9% of new diagnoses in Poland. The use of inpatient CNB to diagnose breast cancer differed significantly across provinces, from 0.6% to 34.4%. CONCLUSIONS OSBs are too often used to diagnose focal lesions in breast glands in Poland. In some regions, CNBs are too frequently performed on an inpatient rather than outpatient basis, thereby requiring an analysis of the quality of and access to modern diagnostic methods.

A follow-up study of patients with MEN syndromes - five case reports.

THE AIM OF THE STUDY: Evaluation of the results of surgical treatment in patients with hyperparathyroidism related to MEN syndrome MATERIALS AND METHODS: The group of three women and two men aged between 17 and 72 years ( av. 38.6) with MEN- related hyperparathyroidism within 419 patients were operated between 2010-2016. MEN1 syndrome was diagnosed in four patients and MEN2 only once. Pre- and postoperative results of PTH levels and serum calcium values were compared. RESULTS: The mean preoperative serum PTH level was 215,56 pg/ml, whereas calcium concentration was 1.40 mmol/l. Three Patients with MEN1 syndrome had three and two thirds of parathyroid gland taken, and one had a single parathyroid gland excised with biopsy of the rest glands performed. A patient with MEN2 syndrome had one parathyroid gland excised. Postoperatively, we reported decreased secretion of both PTH (a mean serum PTH concentration 6.72 pg/ml), and serum calcium concentration 1.11 mmol/l. One patient (25%) with MEN 1 developed recurrent hyperparathyroidism after five years from the surgery. The patient was reoperated. The rest of the parathyroid gland was removed with an implantation into separated muscle pockets in the anterior forearm muscles. CONCLUSIONS: 1. MEN syndrome is a rare cause of primary hyperparathyroidism. 2. Subtotal parathyroidectomy helps to bring back a normal calcium metabolism. 3. Recurrence of hyperparathyroidism in patients with MEN syndrome requires total parathyroidectomy with an autotransplantation into the anterior forearm muscles.

Oxidative stress in proliferative lesions of parathyroid gland.

BACKGROUND: Primary hyperparathyroidism (PHPT) is one of the most common endocrine disorders and defined as excessive secretion of parathormone. PHPT is a risk factor of several cardiovascular diseases, which could be caused by alterations in oxidant-antioxidant balance. MATERIALS AND METHODS: Blood serum collected from 52 consecutive patients with PHPT treated surgically constituted our study material, whereas 36 healthy volunteers were our control group. Oxidative stress was evaluated in both patients and control subjects by assessment of malondialdehyde (MDA) and lipid hydroperoxides (LHP). Antioxidants were evaluated by the measurement of superoxide dismutase (SOD), ceruloplasmin (CER), catalase (CAT), sulfhydryl (SH) groups, glutathione (GSH), glutathione peroxidase (GSH-Px), glutathione transferase activity (GST) and glutathione reductase (GR). Moreover total antioxidant capacity (TAC) and total oxidative status (TOS) were measured and oxidative stress index (OSI) was calculated. RESULTS: OSI was increased in patients with PHPT when compared to normal controls, whereas TAC was lower in PHPT. The levels of CER, MnSOD, GR, SH groups and MDA were significantly decreased in PHPT. The levels of serum LHP, catalase and SOD were significantly higher in patients with PHPT than in healthy patients. The erythrocyte CAT activity and GST were significantly increased in patients after parathyroidectomy. The erythrocyte GR and GPx were up-regulated postoperatively, whereas SOD activity decreased. CONCLUSIONS: In PHPT there are several alterations in the balance between the production of reactive oxygen species and antioxidant defense system.

Oxidative stress and angiogenesis in primary hyperparathyroidism.

BACKGROUND: The inappropriate elevation of parathormone (PTH), which regulates the process of angiogenesis in parathyroid tissue, causes the changes of activity of enzymes responsible for the removal of free radicals. Parathyroidectomy (PTX) in patients with primary hyperparathyroidism (PHPT) lowers the level of PTH and leads to the reduction of risk of cardiovascular and all-cause mortality by normalization of the antioxidant status. Therefore, the aims of the study were to assess the activity of antioxidant enzymes and free radical reaction products in patients after parathyroidectomy, and to evaluate the correlation between the systemic oxidative stress and angiogenic parameters. MATERIALS AND METHODS: Patients with PHPT treated surgically were enrolled into the study. Total antioxidant capacity (TAC), total oxidative status (TOS), oxidative stress index (OSI), superoxide dismutase (SOD), ceruloplasmin (CER), lipid hydroperoxides (LHP) and malondialdehyde (MDA) were measured before and after parathyroidectomy. The immunohistological expression of angiogenic factors in parathyroid specimens was assessed by the BrightVision method from ImmunoLogic using murine monoclonal anti-human: anti-VEGF, anti-CD31 and anti-CD106 antibodies. RESULTS: The significant increase of TAC, CER, reduction of TOS, MDA, SOD, especially for cytoplasmic form, and significant decrease of OSI, LHP were observed after PTX. There was no significant correlation between changes of oxidative stress markers and angiogenic parameters: VEGF, CD-31, CD-106 in parathyroid tissue. The correlation level was low and medium. CONCLUSIONS: Parathyroidectomy causes down-regulation of lipid peroxidation processes and leads to reduction of oxidative stress in patients with PHPT. The decrease in the OSI is the results of down-regulation of oxidative stress in the postoperative period. The change of the antioxidant status has no impact on angiogenesis processes in parathyroid tissue.

[Diverticulosis of the proximal part of the jejunum causing intestinal obstruction - case report].

Diverticulosis is a rare disease with a multifactorial aetiology, with a large majority in the elderly. It is characterized by a mildly symptomatic and non-specific clinical symptom. Unequivocal diagnosis can be difficult and not always possible before intraoperative examination. Delayed diagnosis can result in life-threatening consequences such as intestinal perforation or hemorrhage. A case of an 86-year-old patient with abdominal pain, nausea, and vomiting lasting for 2 days was reported. In the physical examination of the deviation from the normal state, general abrasion, flatulence and tenderness were found in the mesogastric abdominal area. In the past 6 months, the patient reported weight loss and a change in bowel movements. In laboratory tests, low leucocytosis, with normal levels of C-reactive protein. Despite intensive treatment, no improvement in general condition was observed. Due to persistent abdominal pain and gastrointestinal symptoms, it was decided to perform reconnaissance laparotomy. Several diverticulae of the initial small intestine were found in the intestine at ca. 20 cm from the Treitz ligament. The intestines were decompress by cutting them. Due to localization of lesions, no inflammation, perforation or haemorrhage, age and general condition of the patient, resection of the diseased segment of the small intestine was rescued. Perioperative and postoperative course without complications. Patient was discharged home in good general condition 10 days after surgery.

Expression of TRAIL and Fas in Primary Hyperparathyroidism.

AIM: Differentiating between parathyroid lesions is still difficult and ambiguous. In cases of primary hyperparathyroidism, appropriate and prompt diagnosis is of great importance for effective treatment and follow-up. A great amount of mechanisms contribute to the pathogenesis of primary hyperparathyroidism, such as disturbance in balance between pro- and anti-apoptotic factors. Therefore, we examined whether immunohistochemical expression of apoptotic factors, TNF-related apoptosis-inducing ligand (TRAIL) and Fas, could have clinical utility as a marker of proliferative lesions of parathyroid gland. MATERIALS AND METHODS: Parathyroid specimens of 58 consecutive patients who had undertaken surgery due to primary hyperparathyroidism were incubated with purified mouse monoclonal antihuman antibodies: anti-TRAIL and anti-Fas. Staining was considered positive when at least 5% of the cells showed immunoreactivity. RESULTS: The percentage of cells which were positively stained for TRAIL in parathyroid hyperplasia was 9.65%, in parathyroid adenoma 8.31%, and in normal controls 2.24%. Immunoreactivity for TRAIL was detected in 91.89% of parathyroid hyperplasias, 85.71% of parathyroid adenomas, and none in healthy glands. The percentage of cells with a positive reaction to Fas in parathyroid hyperplasia was 8.92%, in parathyroid adenoma 8.09%, and in normal tissue 1.9%. The expression of Fas was found in 94.59% of parathyroid hyperplasias, 90.48% of parathyroid adenomas, and none in healthy glands. CONCLUSIONS: In our study, hyperplasias demonstrated the highest expression of TRAIL and Fas, whereas in adenomas it was increased compared to normal tissue, but lower than in hyperplasias. These factors could be an additive tool in the differential diagnosis of parathyroid lesions.

Telomerase activity in non-small cell lung cancer.

INTRODUCTION: High telomerase activity has been detected in the majority of malignant neoplasms including lung cancer. The purpose of the study was to attempt to use telomerase activity as a prognostic factor in patients with non-small cell lung cancer (NSCLC). MATERIAL AND METHODS: Telomerase activity was analyzed in 47 tissue specimens taken from patients with NSCLC. The control group consisted of 30 specimens of non-cancerous lung parenchyma. Telomerase activity was measured by means of the telomeric repeat amplification protocol (TRAP). RESULTS: Telomerase activity in the neoplastic tissue was significantly higher than in the lung parenchyma that was free from neoplastic infiltration. There was no significant association between telomerase activity and age, gender, tobacco smoking, histological type of the tumor, or staging (pTNM). No association was found between the level of telomerase activity in NSCLC specimens and the two-year survival rate of patients (p = 0.326). A higher level of telomerase activity in poorly differentiated tumors (G3) as compared to moderately differentiated tumors (G2) was detected (p = 0.008). A positive association was identified between telomerase activity in pulmonary parenchyma free from tumor infiltration and the presence of leukocyte infiltration (p = 0.0001). CONCLUSIONS: No association was found between the level of telomerase activity in NSCLC specimens and the two-year survival rate of patients. The study has revealed a positive association between telomerase activity and the grade of differentiation (G) in NSCLC.