PTH level is 230 - Forum

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Surrgeon

PTH level is 230 - Ärzteforum

Post#1 »

A Primary hyperparathyroid lady on whom two Cistamibi scans done 6 months apart were negative. Her Ca++ is 13 and PTH is 230. MRI of the chest showed nothing and the only finding I had to go on was a mass in the left lobe of the thyroid. So I explored. Found a thyroid adenoma. Explored the carotid sheath, up and down the neck, both sides. Found nothing. Her Ca++ is still up as well as her PTH. Going for a bone scan next but her breasts look fine.


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A Doctor

Re: PTH level is 230 - Ärzteforum

Post#2 »

This patient HAS primary hyperparathyroidism, and there IS a missed adenoma in her neck. [Assuming this is the unflawed intact pth assay]

Tc Sestamibi is flawed, but helpful [although not in your case]. Orlo Clark found 71% of single adenomas with it (Arch Surg). MRI is even more flawed.

Is your colleague who explored the neck a regular endocrine surgeon? If he is not, my best advice at this stage is to refer the patient to someone who has done several hundred of these and has a special interest, as the problem of a missed adenoma is a special ball game in surgery, and requires special insights and expertise.

Such a surgeon would collect all existing evidence and materials about the patient, and then repeat some of the tests, adding new ones such as transvenous pth measurement. In the case of the first operation being performed by a less experienced surgeon, I have found that the adenoma is usually in the same old ordinary place on second exploration. When an experienced surgeon misses first time, exotic locations are frequent.

Do specialist surgeons in Utah have the equanimity and wisdom to refer to super-specialist surgeons?

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Treatment guru

Re: PTH level is 230 - Ärzteforum

Post#3 »

In general, I don't do localizing tests before exploring a patient with primary hyperparathyroidism. As in this case, I have found that the tests are often misleading. When you say you found nothing, do you mean you did not find any parathyroid gland? or that you did not find an adenoma?

Arizona

Re: PTH level is 230 - Ärzteforum

Post#4 »

The methylene blue 5mg/kg in 500cc serum infusion before you start the surgical act also is helpful to localize the adenoma.

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Doctor Green

Re: PTH level is 230 - Ärzteforum

Post#5 »

Did you see 4 "normal" glands?

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Lady Surgeon

Re: PTH level is 230 - Ärzteforum

Post#6 »

The next step would be to decide how sick this lady is. If you relly need to ge tthis tumor out I think you need to consider removing her thymus while you look around the mediastinum only after you explore the neck again looking in all the usual places. Having offered this advice I need to tell you that I have never done this

Scalpel

Re: PTH level is 230 - Ärzteforum

Post#7 »

Assuming this was a reliable PTH assay this lady has an adenoma hiding somewhere. Make sure the assay was an intact mid-molecule assay. Sestimibi scans are good but not perfect. Your adenoma is probably somewhere in the chest. What exactly did you find when you explored the patient? Were any normal parathyroids identified and biopsied to prove you really found them? Tif you know what normals are present you will have a much better idea where to look for the missing gland.

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