The management of primary hyperparathyroidism,
what you do here is you, pre-operatively,
you try to localizing getting baseline of
Do a Sestamibi Scan.
I showed you a picture of a Sestamibi Scan
where there was a solitary adenoma of the
If you’ve forgotten, please take a look
at the previous discussion where I very much
showed you that, that’s important.
Ultrasound could also help with establishing
Indication of parathyroidectomy, so if you
actually need to remove the parathyroid because
of this excess calcium, what are the indications?
Symptomatic hypercalcemia; calcium at least
1 milligram per decilitre greater than normal;
age under the age of 50, 24 urine calcium
of being greater than 400 milligrams.
The bone density here, unfortunate well, not
show enough bone because of increased osteoclastic
activity and the calcium stones are found
in the kidney.
All of these to you represent hypercalcemia.
Whenever your patient starts becoming symptomatic
with hypercalcemia and you know for a fact
that it’s being caused by primary hyperparathyroidism,
it’s time for you to start thinking about
moving the parathyroid now.
What you find to be interesting is anytime
that you start doing surgery upon an organ,
what is the possibility always?
There is every possibility that you might
take out too many parathyroids; you might
take out too much of that organ is my point.
If you take out too much of the organ or you
might have collateral damage, say there’s
a nerve passing through there, but in this
case, if you take out too much parathyroid,
then your patient is rendered hypoparathyroid.
And if the patient is suffering from hypoparathyroidism,
obviously, hypocalcemia maybe tetany.
A surgical excision, do… immediate 10 minutes
after excising, what you think is the adenoma.
The PTH half-life is only about three to five
If the PTH drops 50 percent, you’re home
So, now, at this point, you’re suspecting
You immediately do your-your thyroidectomy
and look at this within three to five minutes
the PTH disappears because of the half-life
and if you’re dropped below 50 percent,
stop please; if not, then you keep cutting,
cutting, cutting; if by chance you cut too
much, we just said, may result in hypo…
Medical therapy… medical therapy, bisphosphonates
to decrease fracture risk and something called
cinalcet which is basically to lower PTH secretion.
So, it’s a calcimimetic.
Imagine we give a calcimimetic, the body gets
fooled and so, may...
Now, this is interesting, right?
How many times have we dealt with management
in which, for example, polycystic ovarian
syndrome, when you know your patient has too
much estrogen and you’re giving the patient
perhaps low dose of or contraceptive pill
with estrogen, why?
Because the body actually may respond to this
mimetic, even though within the body itself
there might be too much of that very substance
that you’re giving in vivo.
So, calcimimetic might actually respond, the
patient might actually respond to it and therefore,
may lower the PTH.
Obviously, this is not cure; this is for management.