Parathyroidectomy versus cinacalcet for tertiary hyperparathyroidism; a retrospective analysis.

INTRODUCTION: Tertiary hyperparathyroidism (tHPT), i.e., persistent HPT after kidney transplantation, affects 17-50% of transplant recipients. Treatment of tHPT is mandatory since persistently elevated PTH concentrations after KTx increase the risk of renal allograft dysfunction and osteoporosis. The introduction of cinacalcet in 2004 seemed to offer a medical treatment alternative to parathyroidectomy (PTx). However, the optimal management of tHPT remains unclear. METHODS: A retrospective analysis was performed on patients receiving a kidney transplantation (KT) in two academic centers in the Netherlands. Thirty patients undergoing PTx within 3 years of transplantation and 64 patients treated with cinacalcet 1 year after transplantation for tHPT were included. Primary outcomes were serum calcium and PTH concentrations 1 year after KT and after PTx. RESULTS: Serum calcium normalized in both the cinacalcet and the PTx patients. PTH concentrations remained above the upper limit of normal (median 22.0 pmol/L) 1 year after KT, but returned to within the normal range in the PTx group (median 3.7 pmol/L). Side effects of cinacalcet were difficult to assess; minor complications occurred in three patients. Re-exploration due to persistent tHPT was performed in three (10%) patients. CONCLUSION: In patients with tHPT, cinacalcet normalizes serum calcium, but does not lead to a normalization of serum PTH concentrations. In contrast, PTx leads to a normalization of both serum calcium and PTH concentrations. These findings suggest that PTx is the treatment of choice for tHPT.

Secondary and Tertiary Hyperparathyroidism: A Narrative Review.

End-stage renal disease is often complicated by the occurrence of secondary and eventually tertiary hyperparathyroidism, characterized by increased parathormone, calcium, and phosphate concentrations. Related symptoms include pruritus and osteodynia, concentration difficulties, and feelings of depression may be present. In the long-term, end-stage renal disease patients with hyperparathyroidism have an increased risk of all-cause and cardiovascular mortality. Among treatment options are vitamin D supplements, phosphate binders, calcimimetics, and surgical parathyroidectomy. Determining the optimal treatment for the individual patient is challenging for nephrologists and endocrine surgeons. This review resumes the pathogenesis of hyperparathyroidism, clinical presentation, required diagnostic work-up, and discusses indications for the available treatment options for patients with secondary and tertiary hyperparathyroidism.

Effect of intraperitoneal chemotherapy concentration on morbidity and survival.

BACKGROUND: Selected patients with colorectal peritoneal metastases are treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The concentration of intraperitoneal chemotherapy reflects the administered dose and perfusate volume. The aim of this study was to calculate intraperitoneal chemotherapy concentration during HIPEC and see whether this was related to clinical outcomes. METHODS: An observational multicentre study included consecutive patients with colorectal peritoneal metastases who were treated with CRS-HIPEC between 2010 and 2018 at three Dutch centres. Data were retrieved from prospectively developed databases. Chemotherapy dose and total circulating volumes of carrier solution were used to calculate chemotherapy concentrations. Postoperative complications, disease-free and overall survival were correlated with intraoperative chemotherapy concentrations. Univariable and multivariable logistic regression, Cox regression and survival analyses were performed. RESULTS: Of 320 patients, 220 received intraperitoneal mitomycin C (MMC) and 100 received oxaliplatin. Median perfusate volume for HIPEC was 5·0 (range 0·7-10·0) litres. Median intraperitoneal chemotherapy concentration was 13·3 (range 7·0-76·0) mg/l for MMC and 156·0 (91·9-377·6) mg/l in patients treated with oxaliplatin. Grade III or higher complications occurred in 75 patients (23·4 per cent). Median overall survival was 36·9 (i.q.r. 19·5-62·9) months. Intraperitoneal chemotherapy concentrations were not associated with postoperative complications or survival. CONCLUSION: CRS-HIPEC was performed with a wide variation in intraperitoneal chemotherapy concentrations that were not associated with complications or survival.

ANTECEDENTES: Ciertos pacientes seleccionados con metástasis peritoneales de cáncer colorrectal (peritoneal metastases, PM) se tratan con cirugía citorreductora (cytoreductive surgery, CRS) y quimioterapia intraperitoneal hipertérmica (hyperthermic intraperitoneal chemotherapy, HIPEC). La concentración de quimioterapia intraperitoneal refleja la dosis administrada y el volumen perfundido. El objetivo de este estudio fue calcular la concentración de quimioterapia intraperitoneal durante HIPEC y evaluar si ello se relacionaba con los resultados clínicos. MÉTODOS: Estudio observacional multicéntrico en el que se incluyeron pacientes consecutivos con PM de cáncer colorrectal que fueron tratados con CRS-HIPEC entre 2010 y 2018 en tres centros holandeses. Se obtuvieron los datos a partir de bases de datos mantenidas de forma prospectiva. La dosis de quimioterapia y los volúmenes circulantes totales de solución de perfusión se usaron para calcular las concentraciones de quimioterapia. Las complicaciones postoperatorias y las supervivencias libre de enfermedad y global se correlacionaron con las concentraciones de quimioterapia intraoperatoria. Se realizaron regresiones logísticas univariable y multivariable, regresión de Cox y análisis de supervivencia. RESULTADOS: De 320 pacientes, 220 recibieron mitomicina C intraperitoneal (MMC) y 100 oxaliplatino (OXA). El volumen medio de perfusión para HIPEC fue 5,0 L (rango 0,7-10,0). La mediana de concentración intraperitoneal del agente quimioterápico fue de 13,3 mg/L (rango 7,0-76,0) para MMC y 156,0 mg/L (rango 91,9 - 377,6) en pacientes tratados con OXA. Las complicaciones de grado 3 o mayores ocurrieron en 23,4% (n = 75). La mediana de supervivencia global fue de 36,9 meses (rango intercuartílico 19,5-62,9). Las concentraciones de quimioterapia intraperitoneal no se asociaron con las complicaciones postoperatorias ni con la supervivencia. CONCLUSIÓN: La CRS-HIPEC se realizó con una amplia variación en las concentraciones de quimioterapia intraperitoneal que no se asociaron con las complicaciones ni con la supervivencia.

Role of diagnostic laparoscopy in patients with suspicion of colorectal peritoneal metastases to evaluate suitability for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Background: The aim of the present study was to determine the feasibility and safety of performing diagnostic laparoscopy (DLS) routinely in patients with suspicion of colorectal peritoneal metastases (PM) to evaluate suitability for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). Methods: Data for consecutive patients who underwent DLS between 2012 and 2018 were extracted retrospectively from an institutional database. The primary outcome was the degree of visibility of the abdominal cavity during DLS. Good laparoscopic evaluation of the abdominal cavity was defined as visibility of at least the regions of the diaphragm, pelvis and small bowel. Secondary outcomes were reasons for perioperative exclusion for CRS + HIPEC, major postoperative complications (Clavien-Dindo grade III or above) and difference in overall survival (OS) between patients deemed suitable or unsuitable for CRS + HIPEC. Kaplan-Meier analyses were performed. Results: Some 184 patients were analysed. Good laparoscopic evaluation was possible in 138 patients (75·0 per cent), and 24 (13·0 per cent) had conversion to an open procedure. Ninety-three patients (50·5 per cent) were excluded for CRS + HIPEC, most commonly because of absence of colorectal PM (34 patients, 37 per cent) or extensive disease (Peritoneal Cancer Index 20 or above) (33 patients, 35 per cent). Major complications occurred in five patients (2·7 per cent), with no postoperative deaths. Median OS was significantly decreased in patients who were excluded due to extensive disease (14 (95 per cent c.i. 10 to 18) months) compared with patients suitable for CRS + HIPEC (36 (27 to 45) months) (P < 0·001). Conclusion: Routinely performing DLS in patients with suspicion of colorectal PM to evaluate suitability for CRS + HIPEC is feasible and safe, avoiding the morbidity of an unnecessary laparotomy in patients with extensive disease.

Antecedentes: El objetivo del presente estudio fue determinar la viabilidad y seguridad de realizar una laparoscopia diagnóstica (diagnostic laparoscopy, DLS) de rutina en pacientes con sospecha de metástasis peritoneal (peritoneal metastasis, PM) de origen colorrectal para evaluar la idoneidad para la cirugía citorreductora con quimioterapia intraperitoneal hipertérmica (cytoreductive surgery + hyperthermic intraperitoneal chemotherapy, CRS+HIPEC). Métodos: Los datos de los pacientes consecutivos que fueron sometidos a DLS entre 2012 y 2018 se obtuvieron retrospectivamente de una base de datos institucional. La visualización de al menos las regiones de los diafragmas, pelvis e intestino delgado se definió como una correcta evaluación laparoscópica de la cavidad abdominal. Los resultados secundarios fueron las complicaciones postoperatorias mayores (Clavien­Dindo grado ≥ III), razones para la exclusión perioperatoria para CRS+HIPEC y diferencia en supervivencia global (overall survival, OS) entre pacientes que se consideraron apropiados y no apropiados para CRS+HIPEC. Se realizaron análisis de Kaplan­Meier y análisis de riesgos proporcionales. Resultados: Se analizaron 181 pacientes. En 138 pacientes (75,0%) fue posible una adecuada evaluación laparoscópica, mientras que 24 casos (13%) fueron convertidos a un procedimiento abierto. Se excluyeron 93 (50,5%) pacientes para CRS+HIPEC, más comúnmente por la ausencia de PM colorrectales (36,6%) o enfermedad extensa (37,6%). En cinco pacientes aparecieron complicaciones mayores (2,7%), sin mortalidad postoperatoria. La mediana de la OS disminuyó de forma significativa en pacientes que fueron excluidos debido a enfermedad extensa (14 meses, i.c. del 95% 10­18) en comparación con pacientes idóneos para CRS+HIPEC (35 meses, i.c. del 95% 30­40, P < 0,0001). Conclusión: La realización rutinaria de DLS en pacientes con sospecha de PM de origen colorrectal para evaluar la idoneidad de la CRS+HIPEC es viable y segura. La morbilidad de una laparotomía innecesaria puede prevenirse en pacientes con enfermedad extensa o ausencia de PM colorrectales.

[Diagnostic approach and treatment of primary hyperparathyroidism]. / De diagnostiek en behandeling van primaire hyperparathyreoïdie.

- Primary hyperparathyroidism (PHPT) is characterised by elevated serum calcium levels due to elevated levels, or insufficient suppression, of parathyroid hormone (PTH).- The incidence of PHPT has increased in recent years. This is mainly the result of more frequently performed routine measurements of serum calcium, e.g. as part of postmenopausal screening.- The classically described features of PHPT - bones and stones - are not always observed and most patients are asymptomatic.- Diagnosis of PHPT is only established by biochemical testing, not by imaging.- Ultrasound and technetium-99m sestamibi SPECT-CT are the first-choice imaging modalities. These investigations are necessary to localize the parathyroid adenomas and thereby facilitate minimal invasive parathyroidectomy (MIP).