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In last May his neck showed parathyroid adenoma, but he was advised not to have operation. Since about 2.5 months he's had a mandibular mass(?? brown tumor), oropharyngeal consultation confirmed and sestamibi scan ordered and showed left and right lower parathyroid adenoma.
My questions are: 1) is this secondary or tertiary - pt. has adenoma but still low calcium level- , and 2) how should I proceed with this patient - medical or surgical-??
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Accepted Answer
Peter KerrISN Expert
Sunday, February 14 2016, 09:23 PM - #PermalinkI don't think there is any doubt this is advanced secondary hyperparathyroidism. The question of secondary vs tertiary is probably moot and has little bearing on the plans from here.
As to management, you really have 2 options: cinacalcet or surgery. If cinacalcet is available, it is likely to improve the situation although it is also likely that long term treatment with cinacalcet will be required. Given the severity of the hyperparathyroidism, you may need to start with 60mg/day and wind the dose up according to the response and according to how well the patient tolerates it.
If cinacalcet is not an option, then surgery will be required. However, given that the calcium is on the low side, you could also try more aggressive treatment with the active Vit D (one-alpha or calcitriol) - and ensure that the patient takes a regular dose.
If surgery becomes the only realistic option, remember that in this situation the post-operative calcium requirements are likely to be high and it will be important to pre-load the patient with high dose active Vitamin D and to administer IV calcium post-op. There are several algorithms for this, based around the pre-op ALP level.The reply is currently minimized Show -
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Accepted Answer
Ana CusumanoISN Expert
Monday, February 15 2016, 02:56 PM - #PermalinkDear Mohamed:
Your patient appears to be having secondary hyperthyroidism: long time on dialysis, two "adenomas" on sextamibi scan and a suspected jaw brown tumor. It will help to make the decision and to follow up to know the level of alcaline bone phosphatase.
I suppose Ca is measured in mg/dl.
In my experience, I would proceed with a subtotal parathyroidectomy. He probably has monoclonal parathyroid cells proliferation, but you will confirm that after the surgery.The reply is currently minimized Show -
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Accepted Answer
Tuesday, February 16 2016, 12:38 PM - #PermalinkDear Mohamed,
Hyperparathyroidism in your patient seems to be secondary due to long-term hypocalcemia, if calcium concentration is shown in mg/dl.
In this patient, serum calcium level is low despite the very high level of PTH secreted from enlarged gland.
Do you have any information about the bone turnover ? Any information on bone mineral density and vascular calcification?
If the bone turnover is relatively low despite very high PTH, there should be a severe skeletal resistance to PTH in this patient.
The cause of skeletal resistance to PTH might be due to insufficient dialysis or due to congenital abnormalities of bone cells.
If you cannot solve such a resistance, parathyoidectomy may result in severe hypocalcemia.
So, my recommendation at the moment is to continue to use calcium containing and/or non calcium containing-phosphate binder together with VDRA.The reply is currently minimized Show -
Accepted Answer
Thursday, February 18 2016, 06:51 PM - #PermalinkHere is what the Twitter community thinks about this question:
What would U do? Parathyroidectomy or medical treatment?
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