1. Current Status of Surgery For
Primary and Secondary
Hyperparathyroidism
Surgery Grand Rounds
20 Aug., 2014
W. G. Schenk III

2. Disclosures

3. HYPERPARATHYROIDISM Basic Physiology, Anatomy, Embryology
Primary Hyperpara
Clinical Presentations
Evolution of surgical approach and pre-op imaging
Secondary Hyperpara
Clinical Presentation
Indications for Surgical Rx
Surgical Options

4. PTH and CALCIUM HOMEOSTASIS+
PTH
CALCIUM -

5. PTH and CALCIUM HOMEOSTASIS
n-PTH
c-PTH
Renal c-AMP
Bone Osteoclast
GI Absorption
GI, Renal : 1,25 D
PTH _
Vit D3
Phos ++ Ca
(Albumin)
Calcitonin
(?) +
CALCIUM

6. HYPERPARATHYROIDISM Inappropriate excess secretion of
Parathyroid Hormone
in Primary Hyperparathyroidism
Appropriate Hypersecretion in
Secondary Hyperparathyroidism

8. HYPERPARATHYROIDISM
SURGICAL APPROACES
Embryology
3rd Branchial Pouch: Thymus and
Lower PTH’s
4th Branchial Pouch: Upper PTH’s
Ectopic (5%) and supranumerary (15%)

9. DIAGNOSIS OF HYPERPARATHYROIDISM
PTH Ca PO U. Ca Cl / PO Ca x PO4
> 33
Primary
Secondary
Tertiary
FHH Syndrome
Malignancy

10. Differential Diagnosis of Hypercalcemia
 Primary Hyperparathyroidism
 Malignancy
Bone Metastases
Paraneoplastic
 Medication
Lithium, Vit. A,D, Thiazides
 Granulomatous Disease
 Excess intake,Dehydration, Immobilization
 Familial Hypocalciuric Hypercalcemia (FHH)

11. Symptoms of Primary Hyperparathyroidism
Neurologic
Headache, memory loss
Neurosis, Psychosis
Cardiovascular
Hypertension
Nephrologic
Stones, Renal impairment
Dermatologic
Pruritis, brittle nails
Constitutional
Fatigue, Wt loss, Anorexia GI
Peptic Ulcer Disease
Nausea, Vomiting
Musculoskeletal
Bone and joint pain
Muscle weakness

12. Symptoms of Primary Hyperparathyroidism “ASYMPTOMATIC”
Some symptoms can usually be elicited by careful questioning.
Rationale for surgical Rx in asyptomatic patient.

13. PRIMARY HYPERPARATHYROIDISM
Family History
 MEN I (Wermer’s Syndrome)
Pituitary, Panc Islet Cell
 MEN II (Sipple’s Syndrome)
MCT, Pheo
(MEN IIb)
 FHH (Familial Hypocalciuric Hypercalcemia)

14. PRIMARY HYPERPARATHYROIDISM
Physical Exam
 General : BP, Neuro, Cardiac, Operative risk
 Neck Exam: Thyroid abnormality
adenopathy, palpable mass
Vocal cord function, neck mobility
 Occult Malignancy (Breast, Prostate)

15. LABORATORY EVAL IN PRIMARY HYPER-PTH
 Calcium Determination(s)
 Cl, Po4, Alb, Tot Protein, BUN, Creat., Alk Phos.
** Cl/Po4 ratio > 33
 24-hr Urine ** Ca > 100 mg / day
U-creat., Ca/Cr Clearance ratio, Cyclic AMP
 Chest X-ray
Hand, Bone Xrays (optional)
 PTH Radioimmunoassay

16. PTH Levels in Primary Hyperparathyroidism

17. INDICATIONS FOR SURGERY IN PRIMARY HYPERPARATHYROIDISM
(No prior neck surgery)
Diagnosis of
Hyperparathyroidism Questionable Secure
Symptomatic Asymptomatic Significant
Calcium
Surgical risk Prohibitive Low

18. ANATOMIC CORRELATION:
HYPERPARATHYROIDISM
SURGICAL APPROACES
ANATOMIC CORRELATION:
“Sporadic” Primary – single gland (95%)
Familial Primary
Secondary Multigland Hyperplasia
Tertiary

19. Sporadic Primary Hyperpara: Single Parathyroid Adenoma

20. Hypercellular Parathyroid
800 mg

21. Imaging in Primary Hyper-PTH
Rationale for Pre-op
Imaging in Primary Hyper-PTH
 Identify ectopic and supernumerary glands
Identify multiple adenomas
Provide pre-op anatomic confirmation of biochemical Dx
Reduce incidence of persistent/recurrent hyper-para
Permit “limited exploration”
Reduce complication risk

22. locate an experienced neck surgeon”
“The only pre-op localization necessary is to
locate an experienced neck surgeon”
John Doppman
NIH Concensus Conference
1980

23. Evolution of Imaging Relevence
Hyperparathyroidism
Evolution of Imaging Relevence
 Improvement in imaging technology
 Popularity of limited exploration
Development of rapid PTH Assay
 Economic pressures

24. Jim Norman (based on the past 15,000 PTH operations):
“Our patients get the exact same operation regardless of scan findings – we simply do not care if their scans are positive or negative”
Norman J, Lopez J, Politz D; Abandoning Unilateral Parathyroidectomy; JACS Mar 2012 ; 214(3) :

25. Surgeon-Performed Ultrasound Primary Hyperparathyroidism
Schenk WG, Hanks JB, Smith PW
 Convenience, Efficiency
 Surgical / Anatomic Correlation
 Volume of positive studies
 Additional relevant findings

26. Surgeon-Performed Ultrasound Primary Hyperparathyroidism
Classification of pre-op Neck Ultrasound
 Class 1: Hi Confidence
 Class 2: “Possible”
 Class 0: None seen

27. Primary Hyper PTH: Pre-Op Imaging

28. Results Class 1: 111/200 (55%) 3 patients deferred surgery
107/108 Intra-op agreement
108/108 Cured

29. Results Class 1: 111/200 (55%) 3 patients deferred surgery
107/108 Intra-op agreement
108/108 Cured
Class 0 : 4-D CT Scan
Class 2 : Surgery w or w/o imaging

30. Tc-99m sestamibi scan Coronal slice and 3D reconstruction from a 4DCT

32. CURRENT CONTROVERSIES: “SPORADIC” PRIMARY HYPERPARA
“Limited Exploration” vs. Complete Exploration
Pre-op Imaging
Intra-op PTH Assay
Evolving Approaches:
Minimally invasive / Robotic
Regional Anesthesia
Ambulatory/Outpatient

33. SECONDARY HYPERPARATHYROIDISM
Appropriate  PTH level (Nutritional or Renal).
Renal Failure:
Numerous influences on Ca homeostasis
High proportion of Dialysis pts have elevated PTH.
Less than ten percent should require surgical Rx.

34. Effects of Renal Failure on PTH Homeostasis
 Diminished renal hydroxylation of D3
 Decreased GI absorption of Calcium
 Decreased suppression of PTH by D3
 Decreased (total) serum Calcium
 Decreased renal excretion of phosphorus
 Direct effect of Hyperphosphatemia
 Decreased ionized Calcium
 Elevated “set point” of PTH responsiveness
 Osteoblast resistance to PTH
 Autonomous Hypersecretion from Hyperplasia

35. DIAGNOSIS OF HYPERPARATHYROIDISM
PTH Ca PO U. Ca Cl / PO Ca x PO4
Primary
Secondary
Tertiary
FHH Syndrome
Malignancy +
>55

36. PTH Levels in Secondary Hyperparathyroidism
The majority of
dialysis patients have
some elevation in PTH.
A level in the
pg/ml range is common.
Elevated level alone
is not an indication
for surgical Rx.

37. SECONDARY HYPERPARATHYROIDISM Indications for Surgery
 Failure of reliable maximal medical Rx.
 Development of significant symptoms: Musculo-
skeletal, pruritis, calcinosis cutis, neuro-psych.
 Calcium x Phosphorus product above 70.
 Osteopenia, decreasing measured bone density,
bone biopsy.
 Development of Tertiary Hyper-PTH

39. SECONDARY HYPERPARATHYROIDISM
PRE-OP EVALUATION
 General condition - operative risk.
 Virtually all are dialysis-dependant
 Alk Phos
 Ultrasound (optional); Sestamibi scan not helpful.

40. Identification of all Parathyroid Glands
Neck Exploration
Identification of all Parathyroid Glands

41. SECONDARY HYPERPARATHYROIDISM Surgical Options
Subtotal Parathyroidectomy or
Total Parathyroidectomy with PTH Autotransplant
Essential Components of Either Procedure:
• Complete Neck Exploration
• Identification of All PTH’s
• Ablation of Hyperplastic Glands
• Leave mg Functioning PTH
• Consider temporary central line

42. FAMILIAL PRIMARY (MEN) SECONDARY AND TERTIARY Special Considerations
SURGERY:
FAMILIAL PRIMARY (MEN)
SECONDARY AND TERTIARY
 Subtotal (3 ½ gland) resection
 Total Parathyroidectomy with Autotransplant.
Special Considerations
 MEN I Syndrome
Calcinosis/Calciphylaxis
Tertiary after transplant

46. Subtotal PTH-x vs Total PTH-x with AutoTx
Long – term Recurrence of Secondary Hyper PTH
Patient Compliance
Complexity and Duration of Surgery
Ease / Cost of Post-op Care
Calcinosis – special situation

47. Any
Questions ?