Parathyroid - MEN Reference Materials

Parathyroid 4 glands (2 pairs) posterior to tryoid supplied by inf thyroid a. Physiology Q (Ca) int → 310 PTH (chief cell) → ↑ Ca serum → ↑ absorption of Ca by blood. Direct effect → ↑ shifting of bone Ca to blood. Indirect effect → ↑ Vit D amount by Kidney Serum phosphate ↓ Renal Direct effect Reabsorption of Ca Indirect effect ↑ PTH feed back Ne pituitary PTH (Dwarf feedback) Causes of hypercalcemia AC (hospitalized pt) Cancer (lung, kidney, multiple myeloma) → humoral hyperparathyroidism others: Calcium overdose Hyperparathyroidism Hyperthyroidism Immobilization Paget's Disease (bone) Addisons Disease Zollinger Ellison Syndrome Excess Vit D Excess Vit A Sarcoidosis Stones Kidney stone Bile stone Bones Bone pain Groans Muscle pain & weakness Psychiatry Depression / anxiety Localization US + CT + sestamibi scan Hyperparathyroid Primary adenoma (Solitary) Pituitary adenoma Familial hyperplasia (4) MEN1 & 2A Radiation Sporadic Secondary Renal & GIT loss of Ca (Renal Failure) ↓ Ca ↑ PTH ↓ phosphate Tertiary Renal underplay (Cause) → Ca ↓ Vit D, phosphate binding (treat underlying Cause) + Renal steady state Surgery (subtotal or total parathyroidectomy) Ca in muscle RF Pancreatic islet cell tumor (gastrinoma, insulinoma, glucagonoma) Pheochromocytoma Medullary Carcinoma of thyroid Concerned Solitary Mc farmer worker is HCF ↑ PTH ↓ Ca ↑ Phosphate 2/3 ↓ Ca Stones Bones Groans Psychiatry Muscle pain & weakness Depression / anxiety Localization US + CT + sestamibi scan Hyperparathyroid Primary adenoma (Solitary) Pituitary adenoma Familial hyperplasia (4) MEN1 & 2A Radiation Sporadic Secondary Renal & GIT loss of Ca (Renal Failure) ↓ Ca ↑ PTH ↓ phosphate Tertiary Renal underplay (Cause) → Ca ↓ Vit D, phosphate binding (treat underlying Cause) + Renal steady state Surgery (subtotal or total parathyroidectomy) Ca in muscle Parathyroid 4 glands (2 pairs) posterior to thyroid supplied by inf thyroid a. Physiology Ca (Q) int → 310 PTH (chief cell) → ↑ Ca serum → ↑ absorption of Ca by blood. Direct effect → ↑ shifting of bone Ca to blood. Indirect effect → ↑ Vit D amount by Kidney Serum phosphate ↓ Renal Direct effect Reabsorption of Ca Indirect effect ↑ PTH feed back Ne pituitary PTH (Dwarf feedback) Causes of hypercalcemia AC (hospitalized pt) Cancer (lung, kidney, multiple myeloma) → humoral hyperparathyroidism others: Calcium overdose Hyperparathyroidism Hyperthyroidism Immobilization Paget's Disease (bone) Addisons Disease Zollinger Ellison Syndrome Excess Vit D Excess Vit A Sarcoidosis Stones Kidney stone Bile stone Bones Bone pain Groans Muscle pain & weakness Psychiatry Depression / anxiety Localization US + CT + sestamibi scan Hyperparathyroid Primary adenoma (Solitary) Pituitary adenoma Familial hyperplasia (4) MEN1 & 2A Radiation Sporadic Secondary Renal & GIT loss of Ca (Renal Failure) ↓ Ca ↑ PTH ↓ phosphate Tertiary Renal underplay (Cause) → Ca ↓ Vit D, phosphate binding (treat underlying Cause) + Renal steady state Surgery (subtotal or total parathyroidectomy) Ca in muscle RF Pancreatic islet cell tumor (gastrinoma, insulinoma, glucagonoma) Pheochromocytoma Medullary Carcinoma of thyroid Concerned Solitary Mc farmer worker is HCF ↑ PTH ↓ Ca ↑ Phosphate 2/3 ↓ Ca Stones Bones Groans Psychiatry Muscle pain & weakness Depression / anxiety Localization US + CT + sestamibi scan Hyperparathyroid Primary adenoma (Solitary) Pituitary adenoma Familial hyperplasia (4) MEN1 & 2A Radiation Sporadic Secondary Renal & GIT loss of Ca (Renal Failure) ↓ Ca ↑ PTH ↓ phosphate Tertiary Renal underplay (Cause) → Ca ↓ Vit D, phosphate binding (treat underlying Cause) + Renal steady state Surgery (subtotal or total parathyroidectomy) Ca in muscle Techary Presistance secunding hyperparathyroidism (long standing hypocalcemia) Por normal CaPTH usually nothing → Remove + reimplant. 10% But if total or subtotal lead to Auknomous hyperfunctioning of gland) Diagnosis Presence Parathyroidectomy lab Ca-PTH-phosphate → urin Ca (famullial hypercalcimere hypocalcuric disease) Treatment localization CT, US Sestombi Scan (echopic) (2 out of 3) →Hyperplasia •Remove all 4 gland + reimpla 30 mg in or leave the smallest 2 faithuyend adenoma selective fouthjoontestery C hand ron domount gland Remove adenoma (uts or sistamed or nuclear soun) + at ofe Serum paratigroid level (50% in 10 min) Carcinoma Riomove Cancer + ipsilateral thyrod lobe + modified neck dissection Complication of surgery -Recortand lasengral nerve injury. Ca muscle Cramps - telany Chaustic sign -trossus Sign - Pasacral snubnes -hanger bone sign (Galican in bore + Ca in blood) Hypo parathyroidisme -Secondary to paradhy raidedomy - Due to ischemia or accidental removal mild oral numbness-chovostic sign can be asymptomatic symptomatic give oral Ca "Sever Tachycardia - Convulsion give IV ca 10 mL of 10% in 10 min Pituitary Adenoma → benign tumor arising from Ant lobe Macro adenoma Microadenoma 1 cm < 1 cm Visual loss (bilateral hemianopsia) * SxS depend on type of hormone hypopituitarism overproduction headache hyperprolactinemia Prolactinoma MC: secondary amenorrhea, galactorrhea GH producing tumors: gigantism, acromegaly coarse facial features, thick finger & toe pads cardiomegaly, hepatomegaly, large mandible, goiter neuropathy, arthropathy, osteoporosis, HTN, DM morbidities: Diabetes insipidus Cerebrovascular accident, meningitis. Diagnosis: Imaging + clinical presentation. Treatment: medical Prolactinoma Bromocriptine → Somatostatin (↓ size, normalize GH) Pre operative Complete endocrine assessment, electrolyte (Diabetes insipidus) surgery → Transsphenoidal approach (better) Transcranial approach + Perioperative steroid + Serial visual field assessment & endocrine Radiation therapy Post operative in large lesions Primary when surgery Contraindicated MEN multiple endocrine neoplasia Autosomal Dominant MEN 1: wermer's syndrome Pituitary adenoma Parathyroid hyperplasia Pancreatic islet cell tumor (gastrinoma - insulinoma - glucagonoma) MEN 2A: Sipple's Syndrome Pheochromocytoma 33% Medullary Carcinoma of thyroid 100% Parathyroid hyperplasia 50% MEN 2B: Pheochromocytoma 50% Medullary Carcinoma of thyroid 85% marfanoid habitus (kyphosis - Pectus excavatum) mucosal neuroma (hypertrophved lips * thickend eyelids) 100% early sign