Primary hyperparathiroidism. Our experience

During the last years an increasing number of patients affected by primary hyperparathiroidism has been revealed by the routine determination of blood levels of calcium, phosphate and parathyroid hormone. According to US hepidemiologic evaluations, the incidence of this affection is estimated in 0.3-0.5% of general population. The etiology of primary hyperparathyroidism is related to a single adenoma in 80-85% of cases, to a diffuse gland hyperplasia in 10-15% and to a carcinoma in 1-5%. The clinical picture is protean with different features which can be variously associated (nephrolithians, gastropathy, pancreatitis, osteoporosis, depression, neurological alterations etc.). A logical and correlated sequence of diagnostic procedures (neck ultrasonography with fine needle biopsy, color doppler imaging, technetium 99 sestamibi scintigraphy. 201 Tl or 99 Tc subtraction scanning. Computed Tomography and Magnetic Resonance, seldom a selective arteriography or selective venous sampling) almost always allows a correct diagnosis and an exact localization of gland affected. Surgical exploration with eventual support of ultrasonography and intraoperative real-time determination of intact- PTH blood levels, represents the final step of diagnostic and therapeutic sequence. Our experience consists of 280 patients with parathyroid affections, with a strongly increasing number of cases during the last decade. 185 patients were affected by primary hyperparathyroidism. 94 by secondary hyperparathyroidism, 1 by a parathyroid cyst. The 185 patients with primary hyperparathyroidism were 39 men (21.6%) and 146 women (78.4%). The mean age was 49 years. The main symptoms were related to musculo-skeletal, urinary, gastroenteric and neuropsychial systems and presented alone or variously associated. In 5 patients (2.9%) a severe acute hyperparathyroidism was diagnosed. The choice of diagnostic procedures was influenced to the period of observation, with an improved correlation in patients treated in the last five years, particularly for which concerns the detection of persistences and recurrences. 196 surgical procedures were performed. 185 primary operations and 11 reoperations. A single adenoma was found in 88% of cases, a diffuse hyperplasia in 6.4%, multiple adenomas in 5%, a carcinoma a 0.6%. In case of diffuse hyperplasia (12 pts.) a parathyroidectomy was performed with a exact correlations between removal of pathological tissue and decreasing of intraoperatively determined PTH blood levels. In 23 cases the parathyroid adenoma was found in atypical sites: in 12 cases it was within the thymus gland, in 8 cases retroesophageal, in 6 cases in the upper mediastinum, in 4 cases within the thyroid gland and in 3 in para-aortic location. 9 patients had a synchronous thyroid cancer: in 7 cases papillary and in 2 cases medullary. As we have said, 11 patients were submitted to reoperations for persistence or recurrence (13 cases observed within our patients, that is 7% of insuccess). The 11 reoperations, performed through a cervicotomy in 9 cases and through a cervicosternotomy in 2 cases, were always successful, which was confirmed by the support of the intraoperative real time determination of PTH blood levels. Overall complications were limited: 2 recurrent laryngeal nerve lesions with 1 monolateral persistent paralysis and 1 transient paralysis, and 18 hypocalcemias, 2 of which persistent.