HYPERPARATHYROIDISM Shariati Thursday Conference

ParaThyroid Hormone (PTH)  Biochemistry  Physiology  pathophysiology Hyperparathyroidism  Clinical manifestation  Diagnosis ◦ Lab finding ◦ imaging  treatment

Biochemistry  Parathyroid Glands (4 glands 6*3*2 mm.)  84 aa protein (9500 D)  Receptor in target cell (osteoblast, osteoclast, renal tubules)  cAMP enzym release reaction catalysis

Physiology GI intake Urinary out put Bone PTH Vit D Calcitonin GI Sweat

GI intake Urinary out put Bone GI Sweat P h y s i o l o g y mg 10-70% mg >4mg/kg abn. 7g 98% Vit D

GI intake Urinary out put Bone Ca GI Sweat P h y s i o l o g y. 99%=1-2kg Intra cellular Ca 0.1% 1% Pr.Bound Ca 40% Non-ionized Ca 10% Ionized Ca 40%

Bone Ca Kidney Ca GI Ca In minutesOsteocyt&blast In daysOsteoclast

Pathophysiology ◦Primary hyperpara ◦Secondary hyperpara ◦Tertiary hyperpara ◦pseudohyperpara

Pathophysiology ◦Primary hyperpara ◦ Diffiuse hyperplasia10-40% ◦ Single adenoma50-80% ◦ Multiple adenoma 10% ◦ Carcinoma1% ◦Secondary hyperpara ◦Tertiary hyperpara ◦pseudohyperpara

Pathophysiology ◦Primary hyperpara ◦Secondary hyperpara ◦ Secondary to hypocalcemia  Renal dysfunctionP  MalabsorptionP ◦Tertiary hyperpara ◦pseudohyperpara

Pathophysiology ◦Primary hyperpara ◦Secondary hyperpara ◦Tertiary hyperpara ◦ Autonomus hyperactivity after secondary hyperpara ◦pseudohyperpara

Pathophysiology ◦Primary hyperpara ◦Secondary hyperpara ◦Tertiary hyperpara ◦pseudohyperpara ◦ Hypercalcemia of malignancy without metastasis or primary hyperpara

Pathophysiology ◦Primary hyperparaCa / N ◦Secondary hyperparaCa / N ◦Tertiary hyperpara ◦pseudohyperpara

Pathophysiology ◦Osteoclast/Osteoblast ◦Osteoclast activity ◦Osteoblast activity ◦Remodeling activity

Clinic  100,000 new case / year in USA  1/1000  4 th and 6 th decade  F/M = 2/1

Clinical findings: ◦Renal ◦Gastrointestinal ◦Skeletal manifestation ◦CNS ◦Skin ◦Cardiovascular ◦hypercalcaemia common rare nowadays

Renal  Urinary tract calculi  Nephrolithiasis Gastrointestinal  Peptic ulcer  Pancreatitis Skeletal 10-25%  Tenderness  Aching pain (peripheral joints & vertebrae)  Sever pain, swelling, deformity

Rare manifestations:  CNS Personal disturbance, coma, fatigue  Skin Dry skin, itching  Cardiovascular Hypertension, CHF

Lab exam, ◦Ca ◦P ◦Alk Ph. ◦Urin Ca

Lab exam, ◦Ca  PrimaryUp-N  SecondaryN-Low  Total Ca50% ionic calcium (acidosis, hypoproteinemia) ◦P ◦Alk Ph. ◦Urin Ca ◦PTH

Lab exam, ◦Ca ◦P ◦ Primary Low ◦ SecondaryUp/Low ◦Alk Ph. ◦Urin Ca ◦PTH

Lab exam, ◦Ca ◦P ◦Alk Ph. ◦ Hyperphosphatesia ◦Urin Ca ◦PTH

Lab exam, ◦Ca ◦P ◦Alk Ph. ◦Urin Ca. ◦ Hypercalciurea ◦PTH

Lab exam, ◦Ca ◦P ◦Alk Ph. ◦Urin Ca. ◦PTH ◦ Up ◦ Rarely N

Radiologic findings, ◦Bone resorption ◦Bone survey  Bone resorption of hand is highly sensitive  If high quality macroradiography/digitalized radiograhy ◦Bone densitometry

Radiologic findings, ◦Bone resorption ◦Bone survey  Bone resorption of hand is highly sensitive  If high quality macroradiography/digitalized radiograhy ◦Bone densitometry

Bone resorption  Subperiosteal  Juxtaarticular  Intraarticular, (high turn over, hyperthyroidism)  Subchondral  Endosteal, (MM, Osteoporosis)  Subphysial  Trabecular  Sublig. And sub tendinous  Brown tumor

Bone resorption  Subperiosteal  Juxtaarticular  Intraarticular, (high turn over, hyperthyroidism)  Subchondral  Endosteal, (MM, Osteoporosis)  Subphysial  Trabecular  Sublig. And sub tendinous  Brown tumor

Subperiosteal resorption  Diagnostic (prominent)  DD: chronic renal disease  Radial aspect of the hand phalanx  Middle phalanx  Index & middle finger

Subperioseal resorption  Progressive lace like appearance

Subperioseal resorption  Progressive lace like appearance speculated contour

Subperioseal resorption  Progressive lace like appearance speculated contour complete resorption of cortex

Subperiosteal resorption  Other sites;  Phalanx tuft  Medial proximal tibia, femur,humerus  Upper and lower border of the rib  Lamina dura Subperiosteal resorption  Other sites;  Phalanx tuft  Medial proximal tibia, femur,humerus  Upper and lower border of the rib  Lamina dura

Subperiosteal resorption  Phalanx tuft, acro-osteolysis

Subperiosteal resorption  Phalanx tuft, acro-osteolysis

Subperiosteal resorption  Phalanx tuft, acro-osteolysis

Trabecular resorption  Medullary bone  In advance stages  Granular appearance  In cranium is caractristic osteopenia+speckled appear=Salt and Pepper

Trabecular resorption

Brown tumor  Osteoclastoma  Specially in primary hyperpara  Fibrous tissue+giant cells  Radiologic app. ◦ Single or multiple ◦ Well defined ◦ Axial or appendicular skeleton ◦ Cortical or eccentric ◦ Could be expansile ◦ Common sites; face bones, pelvis, rib, femur

Brown tumor  Usually after other signs  Occasionally as presenting finding

Diagnosis ◦Lab exam  Ca  PTH ◦Preoperative study  Tc labeled Sestamibi

Treatment ◦Surgery ◦ Adenoma resection ◦ Resection of 3.5 gland ◦ Post operative care

Thank you for your attention