Parathyroid gland short note by S.

Wichien (SNG KKU)

Anatomy -4 glands (< 4 gland=3% ) -golden yellow/light brown -7mm in size -rtpyramid, ltcrescent -40-50 mg/each -br of ITA, STA (20%upper gland) -adrenal cotexmesoderm -adrenal medullaectoderm Sup gland (4th branchial pouch) 80% -post of upper&middle thyroid -dorsal to RLN -level of cricoid 1% -upper gland in paraeso/retroeso Ectopic gland -middle/post mediastinum -aortopulmo window Inf gland (3rd branchial pouch) -most com--1cm from ITA cross RLN -ventral to RLN -15%--in thymus, 2%--intrathyroid Histo 1.chief cell&oxyphil cell -arrange in trabeculae -produce PTH 2.stroma -composed adipose cell 3.water clear cell Physiologic PTH=regulate ca level 1.bone reabsorption -stimulate osteoclast -release ca/po 2.kidney -reabsorb ca in prox tubule -inhi excrete ca in distal tubule -inhi reabsorb bicarb--Met.acidosis -inhi reabsorb PO--Hypophosphate 3.intes ca absorption 1,2direct effect 3indirect effect Calcitonin -C cell -antihyper ca -inhi bone reabsorp -marker of MTC Vit D -liver--25-vit D -kidney--1,25 vit D--active form -stimu absorb of ca/PO from gut -stimu reabsorb ca from bone

Parathyroid gland short note by S.Wichien (SNG KKU)

1Hyperparathyroid -PHPT, f>m -80%--single adenoma 20%--multiple adenoma/hyperplasia 1%--ca -if abnor >1 gland intra/pre-op, pt has all gland abnor until not Etiology -exact=unknown -XRT 30-40 yr after expose -lithium Tx Genetic Sporadic -most case MEN1 (Tsup gene.chro11) -most common=PHPT -50%=gastrinoma -10%=insulinoma -10-50%=prolactinoma MEN2a (RET proto-onco.chro10 ) -20%=HPT Fam.HPT with jaw tumor synd -predispose ca parathyroid Clinical asymptomatic <5% Classic pentads -kidney stone -painful bone -abdo.groan -psychic moan -fatigue overtone Renal dz -kidney stone--CaPo/oxalate -nephrocalcinosis--parenchyma calcify -polydipsia,polyurea,HT Bone dz -osteopenia,osteoporosis -osteitis fibrosis cystica (inc bone turnover,inc ALP) :subperiosteal bone resorption :along radial of middle finger :pathognomonic -bone pain -patho.Fx Clinical (cont) GI -asso PU -cholelithesis -acute pancreatitis Neuropsychiatric -psychosis -depress,anxiety,fatigue Others -prox m weakness -gout,chondrocalcinosis PE -seldom neck mass--if can=ca -band keratopathy :ca deposit in Bowman mb in iris -Fibro-oeeeous jaw tumor :fam.PHPT DDX of hyperca -HPT -malignancy--MM,solid tumor (PTHrP) -endocrine--hyperthyroid,VIPoma -granulomatous--sarcoi,TB,histo -milk alkali syn--antacid -drug--thiazide,Li,vit A/D intox -fam.hpocalciuric hyperca (FHH) -paget dz -immobilization Serum test ca PTH Cl Po Cl:Po ratio Mg uric ALP Acid base Ca:Cr ratio 1,25 vit D Urine test 24 hr ca inc inc inc dec inc (>33) -/dec in OFC -/inc -/inc mild hyperCl-met acido >0.02 (<0.01 FHH) -/inc -/inc (<100mg/d FHH)

Parathyroid gland short note by S.Wichien (SNG KKU)

1Hyperparathyroid (cont) Imaging -hand/skull x ray--OFC -BMD -u/s--stone -preop parathyroid localization Parathyroid localization Pre-op noninvasive 1.99mTc-label sestamibi -most widely use -sens >80% detect adenoma 2.Neck u/s -sens >75% detect adenoma -use iden juxta-intrathyroid parathy 3.CT/MRI -localized ectopic (medias) gland -less sens than 1 Pre-op invasive 1.FNAB -dx parathyroid tumor from LN 2.angiogram -roadmap for venous sampling -Tx of medias tumor by embolize 3.venous sampling -equivocal case Intra-op 1.PTH assay -immediate confirm -10 min s/p s-->PTH fall 50% 1Hyperparathyroid Tx Med Tx -selective estrogen R modifier -bisphosphonate -calcimimetic -->cinacalcet hydrochloride f/u biannual ca, annually BMD+cr I/C for sx -classic symptom -develop c/p -<50yr I/C for sx in asymp pt -ca>1 mg/dl above normal limit -life threatening hyperca -dec cr clearance 30% -kidney stone -24 hr urine ca >=400 mg/d -dec BMD >2.5 SD ,T score <-2.5 -age>50 yr -long term med not desire Parathyroid ca (1%) Pre-op suspect -severe symp -ca >14 -signi hi PTH (x5) Intra-op suspect -invade m,thyroid,RLN,trachea,eso -enlarge LN Sx -bilat neck exploration -en bloc excision tumor & ipsil thyroid -MRND--in LN metas Dx post-op -review adequacy of previous sx -re-op in locally recur/metas (control hyperca) Unresect -XRT -bisphosphonate -cinacalcet hydrochloride Fam.HPT -multiglandular -supernumerary gland -recur/persist dz Tx -not focus sx -scan,u/s--iden ectopic gland Sx -std bilat neck explor + Bilat cervical thymectomy -Both subtotal parathyroidectomy or Total parathyroidectomy+autoTx adenoma in fam PHT -resect adenoma & ipsil normal gland -normal contralat=mark+Bx Neonatal HPT -aso CASR gene mutation -urgent total parathyroidectomy + Auto-Tx + thymectomy -subtotal = hi recurrent Parathyromatosis -follow previous parathyroidectomy -multiple nodule at neck,medias Tx -rare curative F/u -ca 2 wk p/o-->6 mo-->annually

Parathyroid gland short note by S.Wichien (SNG KKU)

1Hyperparathyroid Sx Operative approach 1.Unilat.exploration -focus only enlarge gland -no sx normal gland -in sporadic case Ctriteria for unilat neck exploration -available pre op localization -single gland disease -not fam dz/MEN -no asso thyroid dz -have intraop hormone essay Method of choice -minimally invasive parathyroidectomy Advantage -dec c/p--RLN inj, hypoparathyroid Disadvantage -miss another adenoma 2.standard bilat.exploration -can't localization pre op -best method for localization -multiple abnormal gland -fam.PHPT,MEN1/2a -thyroid dz minimal abnor gland on side by scan, should prompt bilat explor 3.Identification parathyroid -bloodless field -ligate middle thyroid v -retract thyroid to medial & ant -open space btw carotid sheath-thyro :cricoid cartilage to thymus :iden RLN -85%--found 1cm of ITA&RLN jxn -surround by fat, may conceal in fat -distinguish from fat/thyroid nodule/ LN/ectopic thymus -suspicion nodule--FNA + nss 1cc :very hi PTH--dx 4.Sx depend on No.of abnormal gland A.Single adenoma -80% of PHPT -only 1 tumor can iden,other normal -don't rupture--parathyromatosis -if question other gland--bx+frozen B.Double/tripple adenoma -older pt -excise abnormal gland -bx normal r/o asym hyperplasia C.All enlarged -15% of PHPT -parathyroid hyperplasia -subtotal parathyroidectomy or total parathyroidec+autoTx Subtotal parathyroidectomy -titanium clip at most normal gland -50 mg remnant--prefer inf gland (easy sx if recur--ant to RLN) -if viable--resect other gland -if not viable--subtotal another gland & resect initial remnant Auto-Transplant -non-dominant forearm -horizontal skin incision -over brachioradialis m -parathyroid tissue 1mm/piece -1-2 piece/pocket -Tx 12-14 piece

Parathyroid gland short note by S.Wichien (SNG KKU)

Persist & recurrent HPT -persist--not resolve s/p sx -recur--normo at least 6 m Cause -ectopic parathyroid -supernumerary gland -unrecognized hyperplasia -parathyroid ca -incom sx adenoma -parathyromatosis Ectopic location -paraesophageal -intrathymic -ant mediastinum -intrathyroid--IOUS -carotid sheath -post mediastinum -aortopulmo.window -hi cervical (undescend) Ix 1.confirm dx 2.review previous sx 3.24 hr ca urine--r/o FHH 4.non invasive localized ix +ve = sx -ve = 5 5.selective v cath for PTH +ve = sx (if can localized), med (cant) -ve = med *must pre op localization Tx 1.Hi risk pt, can't localized -med Tx -embolization 2.parathyroidectomy 2HPT -asym enlarge -nodular hyperplasia Cause -CKD--asso hyperPo -2 to inadequate ca/vit D intake Tx -low Po diet,hi ca -Po binder -adequate vitD -calcimimetic Sx 1.ca>11, mark hi PTH>500 2.ca-Po product>70 3.calciphylaxis -limb&life threatening -painful,mottled lesion on ext -necrotic,non heal ulcer 4.progressive renal osteodystrophy 5.soft tissue calcification,max med Procedure -HD before sx -not need localization -subtotal parathyroidectomy (50g) or Total parathyroidectomy + autoTx -upper thymectomy (15-20% pt in thymus) 3HPT -autunomous secretion -s/p KT Sx IC -symptomatic -persist >1yr after success KT Sx -subtotal parathyroidectomy (50g) or Total parathyroidectomy + autoTx

Parathyroid gland short note by S.Wichien (SNG KKU)

Hypercalcemic crisis -mark hi ca 16-20 mg/dl -ca parathyroid/fam.HPT Tx -lower ca level-->sx -re hydrate w nss -keep Uo >100cc/h-->lasix -life threatening-->HD Med Bisphosphonate -60-90 mg iv over 4 hr -inh osteoclast resorption -onset = 2-3d Calcitonin -4 IU/k sc,I'm -inh osteoclast -inc ca excrete -onset = hr, short live Mithramycin -25g/d iv *3-4 d -inh osteoclast -onset = 12hr, d-wk Gallium nitrate -200mg/m2/d *5d -dec ca excrete -onset = 5-7 d Glucocorticoid -hydrocortisone 100mg q 8hr -onset = 7-10d -useful for hemato.ca Hypoparathyroidism -sx--most com--thyroid sx :most--transient--ischemia of gland -neonatal--Di Gorge--lack thymic -mg depletion -familial Resist parathyroid H -renal failure -med--calcitonin,bisphos Fail 1,25 vit D production Resist 1,25 vit D Deposit ca -acute pancreatitis -acute hyperPo -massive bl Txn--hincitrate -hungry bone DDx post op hypocalcemia s/p parathyroidectomy 1.Bone hunger syndrome 2.hypoparathyroid 3.hypomagnesemia