1. HYPERPARATHYROIDISM Shariati Thursday Conference 86 12 16

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

3. 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

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

5. GI intake Urinary out put Bone GI Sweat P h y s i o l o g y 400-1000mg 10-70% 100-300mg >4mg/kg abn. 7g 98% Vit D

6. 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%

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

8. Pathophysiology ◦Primary hyperpara ◦Secondary hyperpara ◦Tertiary hyperpara ◦pseudohyperpara

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

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

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

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

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

14. Pathophysiology ◦Osteoclast/Osteoblast ◦Osteoclast activity ◦Osteoblast activity ◦Remodeling activity

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

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

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

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

19. Lab exam, ◦Ca ◦P ◦Alk Ph. ◦Urin Ca

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

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

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

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

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

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

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

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

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

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

30. Subperioseal resorption  Progressive lace like appearance

31. Subperioseal resorption  Progressive lace like appearance speculated contour

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

33. 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

34. Subperiosteal resorption  Phalanx tuft, acro-osteolysis

35. Subperiosteal resorption  Phalanx tuft, acro-osteolysis

36. Subperiosteal resorption  Phalanx tuft, acro-osteolysis

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

38. Trabecular resorption

39. 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

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

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

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

43. Thank you for your attention