The Importance of the Multidisciplinary Input in the management of Primary Hyperparathyroidism
SN Ali, FF Palazzo, J Jackson and K Meeran
Imperial Centre for Endocrinology
We present a case of a 56 year old Caucasian lady who was referred to us as a tertiary referral. She originally presented to her local district general hospital with renal colic and was found to be hypercalcaemic. She had a raised serum corrected calcium, raised parathyroid hormone and was vitamin D replete. She was hypercalciuric and familial hypocalciuric hypercalcaemia was therefore excluded. She had no past history of note and other than being obese, was otherwise fit and well. In view of the diagnosis of primary hyperparathyroidism and she was referred to the regional university hospital for a work-up in preparation for surgery.
At the Tertiary centre, the localisation studies - sestamibi scan with SPECT and ultrasound scan of the neck - failed to identify a parathyroid adenoma. A CT scan of the neck and thorax were performed as well as venous sampling. The selective venous sampling raised the possibility of a mediastinal source of excess PTH. In view of uncertainty, medical treatment was opted for. She was treated with cinacalcet, which however was poorly tolerated.
She was then referred to our centre for a second opinion. On assessment, she had corrected calcium levels of 2.7 to 2.9mmol/L (NR 2.15-2.60mmol/L) and a PTH level of 10 to 14pmol/L (NR 1.1-6.8pmol/L). Her imaging was reviewed at our multidisciplinary endocrine surgical team meeting and the possibility of a left sided paraoesophageal lesion consistent with a parathyroid adenoma was raised. Despite the inconclusive imaging, a surgical exploration of the neck was performed; three normal parathyroid glands and a parathyroid adenoma were seen. The adenoma was removed and the PTH fell satisfactorily from 14pmol/L to 0.6pmol/L, as did the corrected calcium to 2.35mmol/L on day 1 post surgery. Subsequent follow up has shown her to be cured of hyperparathyroidism with a normal corrected calcium level of 2.44mmol/L and an appropriately adjusted PTH of 4.1pmol/L.
Conclusion: Input from all members of the multidisciplinary team is key to the appropriate management of Primary Hyperparathyroidism. Negative localisation studies are not a contraindication to parathyroid surgery. Cross-sectional imaging and selective venous sampling are rarely required in patients that have not previously had surgery.