Updates in Surgery

Guido Gasparri • Michele Camandona Nicola PalestiniEditors

Primary, Secondary and TertiaryHyperparathyroidism

Diagnostic and Therapeutic Updates

Foreword by Francesco Corcione

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EditorsGuido Gasparri Michele CamandonaDepartment of Surgical Sciences Department of Surgical SciencesUniversity of Turin, Turin, Italy University of Turin, Turin, Italy

Nicola PalestiniDepartment of SurgeryCittà della Salute e della Scienza University Hospital, Turin, Italy

The publication and the distribution of this volume have been supported by theItalian Society of Surgery

ISSN 2280-9848ISBN 978-88-470-5757-9 ISBN 978-88-470-5758-6 (eBook)

DOI 10.1007/978-88-470-5758-6

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Endocrine surgery certainly represents a highly specialized field, within whichparathyroid surgery has long been considered especially specialized and mul-tidisciplinary.

In this very interesting volume, which is also enjoyable to read, my friendGuido Gasparri has succeeded in addressing all the important aspects ofparathyroid diseases. Given the nature of the task, this success, while desir-able, was not inevitable.

Based on cooperation among surgeons, endocrinologists and other special-ists, the volume covers in detail all aspects from the origins of parathyroid sur-gery through to the modern treatment techniques. The embryological, anatom-ic, diagnostic and therapeutic characteristics of the different parathyroid dis-eases are clearly presented with the aid of excellent illustrations and up-to-date references.

This book highlights the remarkable advances made during recent years inthe field of endocrine surgery, from the pioneering work through to the stan-dardization of very difficult technical procedures. Furthermore, everyone whois looking for a reliable update in the treatment of parathyroid diseases willfind accurate messages and guidelines.

The most remarkable feature to emerge from this volume is the importanceof the organizational set-up and the technological advances that offer the sur-geon support when performing such difficult and noble surgery. These aspectsare crucial to the successful treatment of parathyroid diseases.

Thanks are due to Professor Gasparri and to all the eminent authors whohave collaborated brilliantly to produce this book, which offers an easy-to-read and detailed update that will be of value for every surgeon.

Rome, September 2015 Francesco CorcionePresident, Italian Society of Surgery

Foreword

v

The discovery of the parathyroids dates back to the nineteenth century, but theirfunction and the associated diseases remained poorly understood for a long timethereafter. In 1907, referring to the four tiny glands posterior to the thyroid, WilliamHalsted observed that it was “hardly credible that the loss of bodies so tiny shouldbe followed by a result so disastrous”. It was not until 1925 that the first surgicaltreatment of primary hyperparathyroidism was performed, by Felix Mandl inVienna. Three years later, Isaac Olch of Barnes Hospital performed the first suc-cessful parathyroidectomy in the USA. After these initial attempts to treat primaryhyperparathyroidism surgically, the disease was well described and was associatednot only with solitary adenoma, but also with double adenomas and multiglandularhyperplasia. Conventional bilateral cervical exploration has remained the proce-dure of choice until the late 1990s, when minimally invasive procedures began togain acceptance.

Today, hyperparathyroidism is not uncommon: it is the third most commonendocrine disease, after diabetes and thyroid pathology. It seems certain that in thefuture biomolecular studies and genetic testing will open new horizons in the treat-ment of primary hyperparathyroidism. Studies on estrogen receptor gene polymor-phism are also very important, because they might influence both the peripheralaction of parathyroid hormone and regulation of calcium secretion. An importantissue is the role of the calcium sensing receptor mRNA in normal and abnormalparathyroid tissues, and this requires further investigation.

Another controversial point is the real incidence of asymptomatic hyperparathy-roidism. Analysis of outcomes after parathyroidectomy for asymptomatic primaryhyperparathyroidism has demonstrated improvements in all aspects of health status6 months postoperatively, the benefits being particularly evident with regard tobody pain, energy levels, and emotional and physical function.

The exact role of autotransplantation and cryopreservation in parathyroid sur-gery for correction of postoperative hypocalcemia remains a matter of debate.Autotransplantation is a good standardized technique but the indications for cryop-reservation are rare and they should be refined.

vii

Preface

The aim of this book on primary, secondary, and tertiary hyperparathyroidismis to provide the reader with a complete understanding of the history, surgicalanatomy, etiology, pathogenesis, clinical aspects, and medical and surgical thera-pies, including new avenues. The book is intended primarily for endocrine sur-geons, but also for endocrinologists, specialists in internal medicine, nephrologists,urologists, gynecologists, and radiologists.

We hope that readers will find subjects of relevance to daily practice and newtechnical points regarding minimally invasive surgery, intraoperative parathyroidhormone assay, and reoperations.

Turin, September 2015 Guido GasparriMichele Camandona

Nicola Palestini

Prefaceviii

1 History of Parathyroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Guido Gasparri, Michele Camandona, and Nicola Palestini

2 Surgical Anatomy of the Parathyroid Glands . . . . . . . . . . . . . . . . . . . 9Nicola Palestini

3 Parathyroid Hormone Secretion and Action . . . . . . . . . . . . . . . . . . . . 21Giancarlo Isaia, Lorenzo Marchese, Margherita Marchetti,Patrizia D’Amelio, and Giorgia Fornelli

4 Clinical Use of the Parathyroid Hormone Assay . . . . . . . . . . . . . . . . . 29Giulio Mengozzi

5 Etiology and Pathogenesis of Primary Hyperparathyroidism and Hypercalcemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Paolo P. Limone, Maurilio Deandrea, Elena Gamarra, Francesca Garino, Aurora Grassi, Gabriella Magliona, Alberto Mormile, Federico Ragazzoni, Maria Josefina Ramunni, and Paola Razzore

6 Clinical Manifestations of Primary Hyperparathyroidism . . . . . . . . . 57Massimo Procopio, Marco Barale, Ruth Rossetto Giaccherino,Alessandro Piovesan, and Ezio Ghigo

7 Diagnosis and Differential Diagnosis of Primary Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Fabio Orlandi, Federico Arecco, Stefania Corvisieri, and Ilaria Messuti

8 Management of Primary Hyperparathyroidism . . . . . . . . . . . . . . . . . 85Michele Camandona

ix

Contents

9 Preoperative Localization for Parathyroid Surgery in Primary and Secondary Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . 91Giovanni Gandini, Filippo Marchisio, Giuseppe Isolato,Antonella Sargiotto, Michela Zotta, and Gianni Bisi

10 Pathology of the Parathyroid Glands . . . . . . . . . . . . . . . . . . . . . . . . . . 111Eleonora Duregon, Marco Volante, and Mauro Papotti

11 Parathyroid Exploration for Primary Hyperparathyroidism . . . . . . . 117Guido Gasparri, Nicola Palestini, Milena Freddi, Gabriella Sisto, and Michele Camandona

12 Minimally Invasive Video-Assisted Parathyroidectomy . . . . . . . . . . . 133Paolo Miccoli and Gabriele Materazzi

13 Surgical Technique in Reoperations . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Rocco Bellantone, Emanuela Traini, Marco Raffaelli,and Celestino P. Lombardi

14 Genetic Syndromes Associated with Primary Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153Maria L. Brandi and Francesco Tonelli

15 Parathyroid Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Gennaro Favia and Maurizio Iacobone

16 Hypocalcemia After Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . 193Matteo A. Cannizzaro and Massimiliano Veroux

17 Secondary Hyperparathyrodism in Adult Predialysis and Dialysis Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201Luigi Biancone, Gianluca Leonardi, Massimo Gai, and Giuseppe P. Segoloni

18 Indications for Parathyroidectomy in End-Stage Renal Disease and After Renal Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Guido Gasparri, Michele Camandona, Michele Giaccone, Mario Pio Capozzi, and Nicola Palestini

19 Patient Information for Surgery in Primary and Secondary Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231Pier Giorgio Nasi and Lodovico Rosato

Contentsx

Federico Arecco Endocrinology Unit, Gradenigo Hospital, Turin, Italy

Marco Barale Department of Medical Sciences, University of Turin, Turin, Italy

Rocco Bellantone Endocrine and Metabolic Surgery Unit, Agostino GemelliHospital, Università Cattolica del Sacro Cuore, Rome, Italy

Luigi Biancone Department of Medical Sciences, University of Turin, Turin, Italy

Gianni Bisi Department of Medical Sciences, University of Turin, Turin, Italy

Maria L. Brandi Department of Surgery and Translational Medicine, University of Florence, Florence, Italy

Michele Camandona Department of Surgical Sciences, University of Turin,Turin, Italy

Matteo A. Cannizzaro Department of Medical and Surgical Sciences andAdvanced Technologies, University of Catania, Catania, Italy

Mario Pio Capozzi Department of Surgery, Città della Salute e della ScienzaUniversity Hospital, Turin, Italy

Stefania Corvisieri Department of Oncology, University of Turin, Turin, Italy

Patrizia D’Amelio Department of Medical Sciences, University of Turin, Turin, Italy

Maurilio Deandrea Division of Endocrinology, Diabetes and Metabolism, A.O. Ordine Mauriziano, Turin, Italy

Eleonora Duregon Department of Oncology, University of Turin, Turin, Italy

Gennaro Favia Endocrine Surgery Unit, 3rd Surgical Clinic, University Hospitalof Padua, Padua, Italy

Contributors

xi

xii Contributors

Giorgia Fornelli Department of Medical Sciences, University of Turin, Turin, Italy

Milena Freddi Department of Surgery, Città della Salute e della ScienzaUniversity Hospital, Turin, Italy

Massimo Gai Division of Nephrology, Dialysis and Transplantation, Città della Salute e della Scienza University Hospital, Turin, Italy

Elena Gamarra Division of Endocrinology, Diabetes and Metabolism, A.O.Ordine Mauriziano, Turin, Italy

Giovanni Gandini Department of Surgical Sciences, University of Turin, Turin, Italy

Francesca Garino Division of Endocrinology, Diabetes and Metabolism, A.O.Ordine Mauriziano, Turin, Italy

Guido Gasparri Department of Surgical Sciences, University of Turin, Turin, Italy

Ezio Ghigo Department of Medical Sciences, University of Turin. Turin, Italy

Michele Giaccone Department of Surgery, Città della Salute e della ScienzaUniversity Hospital, Turin, Italy

Aurora Grassi Division of Endocrinology, Diabetes and Metabolism, A.O.Ordine Mauriziano, Turin, Italy

Maurizio Iacobone Endocrine Surgery Unit, 3rd Surgical Clinic, UniversityHospital of Padua, Padua, Italy

Giancarlo Isaia Department of Medical Sciences, University of Turin, Turin, Italy

Giuseppe Isolato Department of Diagnostic Imaging and Radiotherapy, Città della Salute e della Scienza University Hospital, Turin, Italy

Gianluca Leonardi Division of Nephrology, Dialysis and Transplantation, Città della Salute e della Scienza University Hospital, Turin, Italy

Paolo P. Limone Division of Endocrinology, Diabetes and Metabolism, A.O. Ordine Mauriziano, Turin, Italy

Celestino P. Lombardi Endocrine and Metabolic Surgery Unit, Agostino GemelliHospital, Università Cattolica del Sacro Cuore, Rome, Italy

Gabriella Magliona Division of Endocrinology, Diabetes and Metabolism, A.O. Ordine Mauriziano, Turin, Italy

Lorenzo Marchese Department of Medical Sciences, University of Turin, Turin, Italy

Margherita Marchetti Department of Medical Sciences, University of Turin,Turin, Italy

Filippo Marchisio Department of Diagnostic Imaging and Radiotherapy, Città della Salute e della Scienza University Hospital, Turin, Italy

Gabriele Materazzi Department of Surgical, Medical, Molecular and CriticalArea Pathology, University of Pisa, Pisa, Italy

Giulio Mengozzi Department of Laboratory Medicine, Città della Salute e dellaScienza University Hospital, Turin, Italy

Ilaria Messuti Department of Oncology, University of Turin, Turin, Italy

Paolo Miccoli Department of Surgical, Medical, Molecular and Critical AreaPathology, University of Pisa, Pisa, Italy

Alberto Mormile Division of Endocrinology, Diabetes and Metabolism, A.O. Ordine Mauriziano, Turin, Italy

Pier Giorgio Nasi Thyroid Disease and Endocrine Surgery, Sedes SapientiaePrivate Hospital, Turin, Italy

Fabio Orlandi Department of Oncology, University of Turin, Turin, Italy

Nicola Palestini Department of Surgery, Città della Salute e della ScienzaUniversity Hospital, Turin, Italy

Mauro Papotti Department of Oncology, University of Turin, Turin, Italy

Alessandro Piovesan Division of Oncological Endocrinology, Città della Salute e della Scienza University Hospital, Turin, Italy

Massimo Procopio Division of Endocrinology, Diabetes and Metabolism, Città della Salute e della Scienza University Hospital, Turin, Italy

Marco Raffaelli Endocrine and Metabolic Surgery Unit, Agostino GemelliHospital, Università Cattolica del Sacro Cuore, Rome, Italy

Federico Ragazzoni Division of Endocrinology, Diabetes and Metabolism, A.O. Ordine Mauriziano, Turin, Italy

Maria Josefina Ramunni Division of Endocrinology, Diabetes and Metabolism,A.O. Ordine Mauriziano, Turin, Italy

Paola Razzore Division of Endocrinology, Diabetes and Metabolism, A.O. Ordine Mauriziano, Turin, Italy

Lodovico Rosato Department of Surgery, ASL4, Ivrea Hospital, Ivrea, Italy

Ruth Rossetto Giaccherino Division of Endocrinology, Diabetes andMetabolism, Città della Salute e della Scienza University Hospital, Turin, Italy

Contributors xiii

Antonella Sargiotto Department of Diagnostic Imaging and Radiotherapy, Città della Salute e della Scienza University Hospital, Turin, Italy

Giuseppe P. Segoloni Department of Medical Sciences, University of Turin,Turin, Italy

Gabriella Sisto Department of Surgery, Città della Salute e della ScienzaUniversity Hospital, Turin, Italy

Francesco Tonelli Department of Surgery and Translational Medicine, University of Florence, Florence, Italy

Emanuela Traini Endocrine and Metabolic Surgery Unit, Agostino GemelliHospital, Università Cattolica del Sacro Cuore, Rome, Italy

Massimiliano Veroux Department of Medical and Surgical Sciences andAdvanced Technologies, University of Catania, Catania, Italy

Marco Volante Department of Oncology, University of Turin, Turin, Italy

Michela Zotta Department of Medical Sciences, University of Turin, Turin, Italy

Contributorsxiv