Surgical approach and outcomes in patients with lithium-associated hyperparathyroidism.
ABSTRACT Patients receiving lithium therapy are at elevated risk of developing hyperparathyroidism. In lithium-associated hyperparathyroidism (LAH), the incidence of multiglandular disease (MGD) is unclear, and the need for routine bilateral cervical exploration remains controversial. Therefore, in LAH patients, surgical approaches, pathologic findings, cure rates, and factors associated with persistent or recurrent disease were investigated.
Retrospective analysis of 27 patients with LAH undergoing parathyroidectomy with the intraoperative parathyroid hormone (PTH) assay.
The median postoperative follow-up was 7 months; 17 patients had >6 months follow-up. Cervical exploration was unilateral in 9, bilateral in 18 (3 were converted from unilateral). Sixteen patients (62 %) had MGD, 12 with four-gland hyperplasia and 4 with double adenomas. Ten patients (38 %) had a single adenoma. Twenty-five (93 %) of 27 patients had initially successful surgery. Of the 17 patients with >6 months follow-up, two had persistent disease and two experienced recurrent disease. All patients with a single adenoma remain free of disease. Three (75 %) of four patients with persistent/recurrent disease had MGD and were receiving lithium at the time of surgery. Patients with persistent/recurrent disease were older (p = 0.01) and had experienced a longer duration of hypercalcemia (p = 0.04).
LAH patients have a high incidence of MGD, and bilateral exploration is frequently necessary. With access to the intraoperative PTH assay, it is reasonable to initiate a unilateral approach because many patients will harbor single adenomas and can be reliably rendered normocalcemic. Patients with MGD remain at higher risk of persistent/recurrent disease.
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ABSTRACT: BACKGROUND: Lithium-associated hyperparathyroidism has been attributed to multigland hyperplasia requiring bilateral exploration and subtotal parathyroidectomy. Recent studies suggest that some patients may have single gland disease and be eligible for minimally invasive parathyroidectomy. METHODS: We performed a retrospective review of a prospective, single institution parathyroid database of 1,010 patients who underwent parathyroidectomy between December 1999 and October 2010. RESULTS: Nineteen patients with a history of lithium therapy and sporadic hyperparathyroidism were identified. Median age was 50 years (16-68); median duration of therapy was 19 years (1-37); 11 (58%) were on active therapy with lithium for multiple reasons. Preoperative median serum calcium was 10.9 mg/dL (10.0-12.3), median parathyroid hormone was 111 pg/mL (60-186). A total of 18 patients underwent preoperative imaging. Of 12 patients with single-site localization, 6 (50%) underwent a minimally invasive parathyroidectomy, 2 (17%) underwent unilateral explorations, 1 (8%) underwent bilateral exploration, and 3 (25%) had concomitant thyroidectomies. Six patients did not localize and underwent bilateral exploration for multigland disease. One patient without preoperative imaging had single-gland disease. In all operations surgeons used intraoperative parathyroid hormone (IOPTH) monitoring and met intraoperative criteria. Median IOPTH decrease was 74% (54-86) in single-gland disease and 85% (76-95) in multigland disease. Median abnormal gland weight was 590 mg (134-6,750) in single-gland disease and 296 mg (145-2,170) in multigland disease. All patients were normocalcemic at a median follow-up of 19 months (2-118). CONCLUSION: Of 19 patients with lithium exposure, 6 (32%) had multigland disease. However, of the 13 (68%) patients with single gland disease, all 12 who had preoperative imaging had single-site localization. If localization suggests single gland disease, minimally invasive parathyroidectomy with IOPTH monitoring can be successfully performed.Surgery 01/2013; · 3.37 Impact Factor
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ABSTRACT: General trends in synthetic bone grafting materials are shifting towards approaches that can illicit osteoinductive properties. Pharmacologics and biologics have been used in combination with calcium phosphate (CaP) ceramics, however, they have recently become the target of scrutiny over safety. The importance of trace elements in natural bone health is well documented. Ions, for example, lithium, zinc, magnesium, manganese, silicon, strontium, etc., have been shown to increase osteogenesis and neovascularization. Incorporation of dopants (trace metal ions) into CaPs can provide a platform for safe and efficient delivery in clinical applications where increased bone healing is favorable. This review highlights the use of trace elements in CaP biomaterials, and offers an insight into the mechanisms of how metal ions can enhance both osteogenesis and angiogenesis.Trends in Biotechnology 09/2013; · 9.66 Impact Factor