Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉Elderly patients with pHPT are at increased risk of bone-related disease and fractures and are more likely to have neuropsychiatric complaints; however, referral for parathyroidectomy in the elderly is often limited due to the perceived risk of surgery. Parathyroidectomy is the only curative treatment. This study found that parathyroidectomy in the elderly was not associated with higher morbidity. Elderly patients with hypercalcemia should be evaluated for pHPT and if confirmed should be considered for parathyroidectomy.

👉Am J Surg. 2021 Sep;222(3):549-553. doi: 10.1016/j.amjsurg.2021.01.027.

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👉Non-classical forms of hyperparathyroidism include:

– Normocalcemic: normal calcium with elevated PTH

– Normohormonal: high calcium with inappropriately normal PTH)

👉These require a parathyroid expert to diagnose.

https://pubmed.ncbi.nlm.nih.gov/32803770/

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• The recent report by Ganly et al:
• They identified the importance of the:
• RTK / RAS /RAF / MAPK and PIK3 / AKT / mTOR pathways in this disease
• At least one receptor tyrosine kinase:
• Was mutated in 20% of HCC tumors, including:
• EGFR (2%)
• ERBB2 (11%)
• PDGFR (2%)
• TSHR (4%)
• MET (4%)
• RET (4%)
• PIK3CA mutations:
• Were found in 2% of HCC tumors and were:
• Mutually exclusive with PTEN mutations (4%)
• TSC1/2 mutations:
• Occurred in 6% of tumors
• NF1:
• Was deleted or mutated in 9% of tumors
• Mutations in NRAS, HRAS, or KRAS:
• Occurred in 15% of tumors:
• NRAS 9%
• HRAS 2%
• KRAS 4%
• Mutations in EIF1AX:
• Occurred in 11% of tumors, and mutations in other EIF1, 2, or 3 genes:
• Occurred in 9% of tumors
• In addition to these mutations:
• Genes which are overexpressed due to whole chromosome duplication of chromosome 7 were found, including:
• BRAF
• RHEB
• EIF3B
• There is currently a phase II randomized clinical trial of the multiple tyrosine kinase inhibitor sorafenib and the mTOR inhibitor everolimus in patients with widely invasive HCC:
• The preliminary evidence has shown a significant response rate for these agents, indicating the importance of this pathway in this cancer

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• El hiperparatiroidismo primario es sufrido por pacientes que presentan niveles séricos elevados de calcio y niveles excesivamente altos de parathormona
  • Otras características generalmente están asociadas con él, pero no son necesarias para el diagnóstico
• En los últimos años, se ha desarrollado un enfoque alternativo para la paratiroidectomía
• La cirugía tradicional se realiza bajo anestesia general y permite explorar todas las glándulas
• Por el contrario, la cirugía mínimamente invasiva se usa en la enfermedad uniglandular con localización preoperatoria de la glándula responsable del hiperparatiroidismo
• El SPECT-Tc 99 sestamibi y la PET-CT son actualmente las técnicas más valiosas para localizar la glándula antes de la cirugía
• Varios estudios han concluido que un enfoque mínimamente invasivo para el hiperparatiroidismo primario es equivalente a la exploración bilateral cuando se usa la monitorización intraoperatoria de la hormona paratiroidea (IOPTH)
• Se han definido algunos criterios de resolución para garantizar durante la cirugía que la glándula responsable de la enfermedad haya sido resecada correctamente.
• Estos son los criterios actuales:
  • Criterios de Roma:
    • Equivalen a una caída mayor al 50% desde el nivel más alto de PTH de preexcisión y / o nivel de PTH dentro del rango de referencia 20 minutos después de la escisión, y / o un nivel de PTH 7.5 ng / dl más bajo que el 10 minutos después del nivel de escisión
  • Criterios de Halle:
    • Requieren que el PTH intra intra operatoria caiga dentro del rango normal bajo (< 35 ng / dL) dentro de los 15 minutos posteriores a la eliminación de todas las glándulas paratiroides hiperfuncionantes
  • Criterios de Viena:
    • Requieren tomar una muestra de PTH preincisión basal antes de la manipulación del cuello
    • La caída de la PTH intraoperatoria mayor al 50% desde el nivel de PTH basal a los 10 minutos de la resección de la glándula indica una operación exitosa
  • Criterios de Miami:
    • Es una disminución del 50% desde el nivel más alto de preincisión o preexcisión de la PTH intraoperatoria obtenido 10 minutos después de la escisión de la glándula paratiroidea hipersecretora
• Es importante saber que la PTH tiene una vida media de 5 minutos para confirmar la extirpación completa del tejido enfermo.

Rodrigo Arrangoiz MS, MD, FACS, FSSO cirujano de tiroides y paratiroides 

Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica compleja / tumores de cabeza y cuello / cirugía endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugía endocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

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• These tumors account for approximately 1% of papillary thyroid cancers and are typically associated with a V600E mutation in the BRAF gene
• Most patients have evidence of disease after initial therapy, and the five-year mortality higher than in patients with classical papillary thyroid cancers
• This variant is characterized by:
  • Elongated tumor cells (height twice the width) lining the papillary structures, involving at least 50% of the tumor
• Proper identification of this variant is critical:
  • As it is associated with a more aggressive phenotype
• They are characterized by:
  • Tumor cells with eosinophilic cytoplasm that are twice as tall as they are wide
• TCV is more likely to present with:
  • Larger tumors
  • Lymph node
  • Distant metastases
  • Extracapsular extension
• Mortality is significantly higher than for classic PTC:
  • Although it is not known why these tumors are more aggressive, it could be related to their molecular profile:
    • As many as 80% may express BRAF 
  • In addition, these tumors are frequently PET positive and radioiodine refractory

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• CT scanning is indicated for retrosternal goiter and can provideinformation on the following:
  • Confirmation of the presence and determination of extent of retrosternal extension
  • A ‘road map’ for the anesthetist:
    • Tracheal deviation and compression
  • Esophageal compression
  • At-risk anatomical structures in the impending surgical field
  • An assessment of malignancy (not accessible by ultrasound)
  • Anterior versus posterior mediastinal extension
  • The likelihood that the goiter can be extracted without the need for a sternotomy:
    • The ‘shape’ of the goiter

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– Suspicion of malignancy

– Compression of the trachea

– Compression of the esophagus

– Quality of life

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