Primary hyperparathyroidism diagnosis new insights of an old dilemma
Carmen Vulpoi1, Cipriana Stefanescu2, Lidia Ionescu3, Felicia Crumpei4, Ioana Vasiliu1, Roxana Balcan1, Jeanina Idriceanu1 & Voichita Mogos1
Primary hyperparathyroidism (PHPT) is a relatively frequent problem in clinical endocrine practice. Minimally invasive parathyroid surgery is the treatment of choice but requires precise preoperatory localization. The most commonly investigation methods are ultrasonography and scintigraphy, but they are not always diagnostic. PTH assay of the aspirate from an ultrasound-guided fine-needle aspiration (USFNA) may confirm the location of pathological parathyroid tissue. The aim of this study was to analyze the role of preoperative localization techniques for primary HPT in 40 patients (7 men and 33 women, aged between 19 and 75 years old) evaluated in the Endocrine Department in 2009. All patients had confirmed PHPT. PTH values were between 112 and 823.9 pg/ml (median n=1565 pg/ml), with hypercalcemia (10.917.7 mg/dl), hypercalciuria (350182 mg/24 h), and hypophosphoremia (1.62.3 mg/24 h). Clinical expression varied from asymptomatic to severe symptoms. All patients had both ultrasonography (not always conclusive for parathyroid), and scintigraphy with 99mTc-tetrofosmin, diagnostic in 25% cases (increased persistent uptake), and negative in 15% cases. The remaining 60% cases showed moderate uptake, concordant with the ultrasound localization in 40% cases, and discordant in 20% (no uptake on the presumed parathyroid adenoma and/or uptake in other areas). USFNA with PTH dosage in the needle-wash was performed in 7 patients. High PTH values of >1000 pg/ml confirmed parathyroid adenoma in 3 cases. Of the 60% patients already operated, 80% are cured -all those localized by concordant ultrasonography and scintigraphy and/or USFNA. CONCLUSION. Preoperative diagnosis of primary hyperparathyroidism implies more than one exploration aiming localization. The lack of correlation between ultrasound and scintigraphy may express the presence active lesions other than those supposed on ultrasonography. US FNA with PTH determination is an effective tool in diagnosing abnormal parathyroid gland but it should be carried out in conjunction with the other investigations and reserved for selected cases.