focus on endocrine neoplasia rome, july 9-10, 2010 claudio marcocci department of endocrinology and...
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Focus on Endocrine NeoplasiaRome, July 9-10, 2010
Claudio MarcocciDepartment of Endocrinology and MetabolismUnit of Endocrinology and Bone Metabolism
University of Pisa, Pisa, Italy
Primary hyperparathyroidism
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Calcium Homeostasis
0
20
40
60
80
100
120
0,4 0,7 1 1,3 1,6 2 2,3 2,6Ca2+, mM
PT
H r
ele
ase
, %
of
ma
xim
al
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Primary hyperparathyroidism (PHPT)
• PHPT is a hypercalcemic state resulting from excessive secretion of PTH from one or more of the four parathyroid glands
• Together with malignancy, PHPT is the most common cause of hypercalcemia
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• Prevalence: 1-2/1000
: = 2-3 : 1
• Incidence: 30:100000/yr
Primary hyperparathyroidism (PHPT)
•85-90% single adenoma
•10-15% hyperplasia
•1-2% double adenoma
•<1% carcinoma
Pathology
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Incidence of Definite or Possible Primary PHPT among Residents of Rochester, Minnesota, 1965 to 2001
Wermers, R. A. et. al. JBMR 2006
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Primary Hyperparathyroidism (PHPT)
FIHP
Carcinoma
<1%
Adenoma
Sporadic
90%
Hyperplasia
MEN1 MEN2A HPT-JTFHH
Familial
10%
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Multiple Endocrine Neoplasia Type 1 (MEN1)menin
Multiple Endocrine Neoplasia Type 2 (MEN2) ret
Familial Hypocalciuric Hypercalcemia (FHH) CaSR
Familial Isolated Hyperparathyroidism associated with Jaw tumor (HPT-JT syndrome) parafibromin
Familial Isolated Hyperparathyroidism (FIHP) menin, parafibromin, CaSR, other genes (?)
Genetics of familial forms of PHPT
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Molecular pathogenesis of sporadic PHPT
Adenoma
menin
parafibromin
PRAD1
Carcinoma
parafibromin
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Clinical forms of PHPT
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Nephrocalcinos
lesioni cistiche+riassorbimento sottoperiosteo
Osteite Fibrosa Cystica
Severe PHPT
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Kidney stones AsymptomaticOvert bone disease
0
20
40
60
80
Cope(1930 - 1965)
Heath(1965 - 1974)
Mallette(1965 - 1972)
Silverberg(1986 - 1993)
% o
f pat
ient
s
Changing pattern of clinical presentation of PHPT
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Bone mineral density in PHPT
70
80
90
100
Lumbar
spine
Distalradius
% c
on
tro
ls
Bilezikian, Rev Endocr Metab Disord, 2000
Lumbar spine
Femoral Neck
Distal radius
PHPT Controls
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• Asymptomatic hypercalcemia with serum calcium levels within 1 mg/dl above the upper limits of normals
• Most patients do not have specific complaints and do not show evidence for any target organ complains
PHPT Today
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Differential diagnosis of hypercalcemia
Less common causes (5-10%)Drugs – vitamin D, lithium, thiazide diureticsSarcoidosisTireotoxicosis
Rare causes (1-2%)Familial Hypocalciuric HypercalcemiaGranulamatous diseaseasNo-Hodkin lymphoma, leukemia
Common causes(> 90%)
Primary hyperparathyroidismMalignancy
PTHrp, TNF, PGE2 (lung, kidney and ovary cancer)
Bone metastases (breast cancer)
Multiple Myeloma
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Evaluation of hypercalcemia
• Albunin-corrected total serum calcium
An increase of albumin-corrected serum calcium associated with increased or inappropriately normal intact PTH is virtually diagnostic of PHPT
Corrected total calcium = measured total calcium + 0.8x(4-serum albumin)
• Intact PTH
• (Ionized calcium)
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Diagnosis of PHPT: Images studies
• Should not be used to make, confirm or exclude the diagnosis
• Controversy on its utility at first surgery• Recommended in patients with
previous failed neck surgery• Prerequisite for minimally invasive
video-assisted parathyroidectomy
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Clinical features of parathyroid carcinoma
Female to male ratio 1:1
Age at diagnosis 10 yrs earlier than benign PHPT (40 vs 50 yrs)
Markes increase od serum calcium and PTH
Palpable mas in the neck (up to 75%)
Renal (60 %) and bone (73%) involvement
• High mortality
• Local recurrences
• Distant metastases
Marcocci et al. JBMR 2008
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Aim of treatment• To normalize serum calcium and PTH levels and improve
other manifestations of the disease
• Appropriate to consider in all patients • Recommended in all symptomatic patients (symptoms of
hypercalcemia, kidney stones, overt bone disease)
Current treatment options
• Parathyroidectomy (PTx) is the only definitive therapy of PHPT
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• Should patients with asymptomatic PHPT be treated by PTx?
• What do we know about the natural history of asymptomatic PHPT followed without surgery?
• Do patients with mild asymptomatic PHPT benefit from PTx?
How should patients with asymptomatic PHPT be managed?
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• Should patients with asymptomatic PHPT be treated by PTx?
• What do we know about the natural history of asymptomatic PHPT followed without surgery
• Do patients with mild asymptomatic PHPT benefit from PTx?
How should patients with asymptomatic PHPT be managed?
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Measurement 1990 2002 2008
Serum calcium(above upper limit of
normal)
1 - 1.6 mg/dl 1.0 mg/dl 1.0 mg/dl
24 hr urinary calcium
> 400 mg/day > 400 mg/day Not indicated **
Creatinine clearance(calculated)
Reduced by > 30% Reduced by > 30% Reduced to < 60 ml/min
Bone mineral density
Z score < -2.0 in forearm
T score < -2.5 at any site §
T score < -2.5 at any site§ and/or
previous fragility fracture
Age < 50 < 50 < 50
* Surgery is also indicated in patients for whom medical surveillance is neither desired, nor possible** Some physicians still regard urine calcium > 400 mg/24 hr as a surgical indication§ Lumbar spine, hip or forearm (1/3 site)
Comparison of new and old guidelines for parathyroid surgery in asymptomatic PHPT*
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• Should patients with asymptomatic PHPT be treated by PTx?
• What do we know about the natural history of asymptomatic PHPT followed without surgery?
How should patients with asymptomatic PHPT be managed?
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Measurement Patients Basal End of follow-up
Serum Ca (mmol/L) 80 2.77 ± 0.09 2.77 ± 0.11
Serum creatinine (µmol/L) 80 87.5 ± 17.7 87.5 ± 20.3
Serum PTH (C-term; ng/L) 49 1110 ± 640 1040 ± 570
Serum PTH (mid-region; ng/L) 13 2360 ± 1090 2160 ± 1170
Urinary Ca (mmol/day) 42 6.5 ± 3.3 6.1 ± 3.3
Creatinine clearance (mL/min) 42 82 ± 26 85 ± 27
Proximal forearm BMD (g/cm2) 80 0.657 ± 0.107 0.631 ± 0.112*
Distal forearm BMD (g/cm2) 80 0.466 ± 0.079 0.464 ± 0.083**
*P < 0.001 vs baseline; **P < 0.05 vs baseline
80 patients with asymptomatic PHPT followed for up to 11 yr (median 3.2 yr)
Biochemical and BMD changes in patients with asymptomatic PHPT followed without surgery
Rao et al. JCEM 1988
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Rubin et al. JCEM 2008
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• Eleven patients died [cardiovascular diseases (n = 5), complications of diabetes mellitus (n = 2), gallbladder cancer (n = 1), unknown (n = 3)]
• Similar baseline serum calcium to those who did not die (10.3 ± 0.1 mg/dl)• Higher baseline PTH (161 ± 25 vs 107 ± 8 pg/ml, P < 0.05)
Rubin et al. JCEM 2008
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Rubin et al. JCEM 2008
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*
* Development of new surgical criteria
20 patients initially followed up without PTx ultimately underwent PTx
Rubin et al. JCEM 2008
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• Should patients with asymptomatic PHPT be treated by PTx?
• What do we know about the natural history of asymptomatic PHPT followed without surgery
• Do patients with mild asymptomatic PHPT benefit from PTx?
How should patients with asymptomatic PHPT be managed?
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50 patients (January 2002-September 2005) who did not met the 1990 surgical guidelines for PTx
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Lumbar spine
Total hip
Distal third of radiusP = 0.0002
Months
Months
Months
Mea
n B
MD
cha
nge
(%)
Mea
n B
MD
cha
nge
(%)
Mea
n B
MD
cha
nge
(%)
PTxNo PTx
PTx
No PTx
PTx
No PTx
P = 0.0002
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BMD changes in mild PHPT
Author Patients Follow-up(months)
Observation Group(OG)
Surgery Group(SG)
Rao et al.JCEM 2004
53 42 LS: +0.5%/yrTotal Hip: -0.6%/yrForearm: +0.4%/yr
LS: +1.2%/yrTotal Hip: +0.3%/yr (P = 0.01 vs OG)Forearm: +0.4%/yr
Bollerslev et al.JCEM 2007
99 24 LS: unchangedFN: unchangedForearm: unchanged
LS: increased (P < 0.01 vs OG)FN: unchangedForearm: unchanged
Ambrogini et al. JCEM 2007
50 12 LS: -1.12% Total Hip: -1.88 %Forearm: -0.55%
LS: +4.6 % (P = 0.0002 vs OG)Total Hip: +2.6 % (P = 0.0001 vs OG)Forearm: - 0.34%
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Aim of treatment
• Parathyroidectomy (PTx) is the only definitive therapy of PHPT• Appropriate to consider in all patients • Recommended in all symptomatic patients (symptoms of
hypercalcemia, kidney stones, overt bone disease)
• Follow up • Asymptomatic patients who do not met the NIH surgical criteria
• Medical management• Vitamin D supplementation• Estrogens, SERMS
Current treatment options
• To normalize serum calcium and PTH levels and improve other manifestations of the disease
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Measurement 1990 2002 2008
Serum calcium Biannually Biannually Annually
24-h urinary calcium
Annually Not recommended Not recommended
Creatinine clearance
Annually Not recommended Not recommended
Serum creatinine Annually Annually Annually
Bone density Annually Annually (3 sites) Every 1-2 yr (3 sites)
Abdominal X-ray Annually Not recommended Not recommended
Comparison of new and old guidelines for patients with asymptomatic PHPT who do not undergo PTx
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Aim of treatment
• Parathyroidectomy (PTx) is the only definitive therapy of PHPT• Appropriate to consider in all patients • Recommended in all symptomatic patients (symptoms of
hypercalcemia, kidney stones, overt bone disease)
• Follow up • Asymptomatic patients who do not met the NIH surgical criteria
• Medical management• Vitamin D supplementation• Estrogens, SERMS• Bisphosphonates• Calcimimetics
Current treatment options
• To normalize serum calcium and PTH levels and improve other manifestations of the disease
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50,000 U/week for 1 month and then monthly
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2-year extension of a 2-year RCT in 42 PM women with mild PHPT assigned to either conjugated estrogen (0.625 mg/d) + MPA (5 mg/d) or placebo
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Total body
Lumbar spine
Femoral neck
Trochanter
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Khan et al. JCEM 2004
Alendronate in mild primary PHPTForty-four patients randomized to alendronate (10 mg daily or to placebo)Two-year studyAfter one year the placebo group was crossed to active
treatment
Total calcium
Ionized calcium
Urinary calcium
PTH
Placebo
Placebo
Placebo
Placebo
Alendronate
Alendronate
Alendronate
Alendronate
Alendronate 24 months Alendronate 24 months
Alendronate 24 monthsAlendronate 24 months
U-NTX
B-ALP
Placebo 12 months Alendronate 12 months
Placebo 12 months Alendronate 12 months
Alendronate 24 months
Alendronate 24 months
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Khan et al. JCEM 2004
Alendronate in mild primary PHPT
Total hip
Forty-four patients randomized to alendronate (10 mg daily) or placebo
Two-year studyAfter one year the placebo group was crossed to active treatment
Distal radius
Femoral neck
Total hip
Lumbar spine
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Mean (SE) change in total femur aBMD Mean (SE) change in lumbar spine aBMD
Mean (SE) change in femoral neck aBMD Mean (SE) change in distal 1/3 radiud aBMD
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• Cinacalcet (Mimpara®) is approved in Europe for:– “Reduction of hypercalcemia in patients with primary HPT for
whom parathyroidectomy would be indicated on the basis of serum calcium levels (as defined by relevant treatment guidelines), but in whom parathyroidectomy is not clinically appropriate or is contraindicated”
Mimpara® (Cinacalcet), Summary of Products Characteristics (SmPC), Amgen, http://www.emea.europa.eu/
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Targeted medical management in PHPT
Potential candidates:•Patients with contraindication to surgery•Patients with complications of previous neck surgery•Patients unwilling to have surgery•Failed parathyroidectomy •Relapse (multi-glandular disease)•Selected asymptomatic patients who met surgical criteria for PTX
Treatment options• Antiresorptive therapy• Cinacalcet• Combined antiresorptive therapy and cinacalcet
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Therapy of PHPT: Summary and Conclusions
• Parathyroidectomy (PTx) is the only definitive therapy of PHPT
• PTx should be considered in all patients with PHPT in the absence of severe comorbidities or contraindication to surgery
• Caution to operate on patients with previous failed PTx or with complication of previous neck surgery
• Targeted medical therapy• Surveillance may be an option in mild,
asymptomatic cases
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PARATHYROIDS 2010From Pathophysiology to the
Clinical Use of PTH
PISA, Italy, February 11-13, 2010
www.parathyroids2010.com
www.parathyroids2010.com
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