Przełom hiperkalcemiczny z powodu pierwotnej nadczynności przytarczyc — przegląd piśmiennictwa i opis przypadku

Hypercalcaemic crisis is an uncommon and potentially life-threatening manifestation of primary hyperparathyroidism, and it is associated with rapid deterioration of the central nervous system, and cardiac, gastrointestinal, and renal function. We present the case of a 76 year-old man in a sudden coma due to hypercalcaemic crisis as a first manifestation of primary hyperparathyroidism. At first, the patient was treated conservatively, his mental status gradually improved in the next three days. On the ninth day after the initiation of therapy, a minimally invasive radio-guided parathyroidectomy was performed. Histologically, the tumour consisted of densely arranged chief cells immunohistochemically positive for PTH antigens, suggesting adenoma. Calcaemia level and PTH were normalised in the immediate postoperative period. A systematic review was performed by consulting PubMed MEDLINE for publications from 1958 to 2011. This review found a total of 499 reported cases of hypercalcaemic crisis due to primary hyperparathyroidism. Manifestations are neurological alterations, and cardiac, renal and gastrointestinal dysfunctions associated with markedly elevated serum calcium and parathyroid hormone levels. The most frequent histology is the parathyroid adenoma. In untreated cases, mortality is 100%. Despite advances in its management, the mortality rate is still 93.5% in patients treated only conservatively. Medical therapy followed by expeditious parathyroidectomy should be considered as the treatment of choice for patients affected by hypercalcaemic crisis due to a primary hyperparathyroidism. (Endokrynol Pol 2012; 63 (6): 494–502)Przełom hiperkalcemiczny jest rzadkim choć potencjalnie zagrażającym życiu objawem pierwotnej nadczynności przytarczyc i jest skojarzony z gwałtownym pogorszeniem funkcji ośrodkowego układu nerwowego, serca, przewodu pokarmowego i funkcji nerek. W pracy zaprezentowano przypadek 76-letniego mężczyzny, u którego pierwszym objawem pierwotnej nadczynności przytarczyc był przełom hiperkalemiczny w postaci nagłej śpiączki. Na początku pacjent był leczony zachowawczo i jego stan psychiczny zaczął ulegać stopniowej poprawie w ciągu pierwszych 3 dni. Dziewiątego dnia terapii wykonano u niego mini inwazyjny zabieg usunięcia przytarczyc pod kontrolą RTG. Histologicznie guz składał się z gęsto ułożonych dużych komórek pozytywnych badaniem imunohistologiczno-chemicznym dla antygenów PTH, sugerując gruczolak. Stężenie wapnia i PTH znormalizowano w bezpośrednim okresie pooperacyjnym. Dokonano systematycznego przeglądu publikacji PubMed MEDLINE w latach 1958–2011. Przegląd zawiera łącznie 499 odnotowanych przypadków przełomu hiperkalcemicznego jako objawu pierwotnej nadczynności przytarczyc. Przejawy to zmiany neurologiczne, dysfunkcja nerek, przewodu pokarmowego i serca związanych ze znacznie podwyższonym stężeniem wapnia i parathormonu w surowicy. W badaniu histologicznym najczęściej diagnozowany jest gruczolak przytarczycowy. W przypadkach nieleczonych odnotowuje się 100-procentową śmiertelność. Mimo postępów w leczeniu, przy terapii tylko zachowawczej, śmiertelność jest nadal wysoka — 93,5%. Leczenie zachowawcze plus szybkie usuniecie przytarczyc powinny być uważane za leczenie z wyboru u pacjentów dotkniętych przełomem hiperkalcemicznym z powodu pierwotnej nadczynności przytarczyc. (Endokrynol Pol 2012; 63 (6): 494–502

Substernal oxyphil parathyroid adenoma producing PTHrP with hypercalcemia and normal PTH level

<p>Abstract</p> <p>Background</p> <p>Parathyroid adenoma is the most common cause of primary hyperparathyroidism. Preoperative serum calcium and intact-parathyroid hormone levels are the most useful diagnostic parameters that allow differentiating primary hyperparathyroidism from non-parathyroid-dependent hypercalcemia. Parathyroidectomy is the definitive treatment for primary hyperparathyroidism. Approximately 5% of patients who underwent parathyroidectomy present with persistent or recurrent hyperparathyroidism due to ectopic localization of the adenoma. Functioning oxyphil parathyroid adenoma is an uncommon histological form, seldom causing primary hyperparathyroidism. Parathyroid adenoma with hypercalcemia exhibiting normal parathyroid hormone level is rare. An incidence of 5% to 33% has been documented in the literature; no etiologic explanation has been given. In 1987, parathyroid-hormone-related peptide was isolated as a causative factor of humeral hypercalcemia of malignancy. The presence of parathyroid-hormone-related peptide in parathyroid tissue under normal and pathological conditions has been described in the literature; however, its role in causing hyperparathyroidism has not yet been defined.</p> <p>Case presentation</p> <p>We present a case of persistent hypercalcemia with a normal level of intact-parathyroid hormone due to a substernal parathyroid adenoma, treated with radioguided parathyroidectomy. The final histological diagnosis was oxyphil adenoma, positive for parathyroid-hormone-related peptide antigens.</p> <p>Conclusion</p> <p>In clinical practice, this atypical biochemical presentation of primary hyperparathyroidism should be considered in the differential diagnosis of hypercalcemia. The parathyroid-hormone-related peptide should be considered not only in the presence of malignancy.</p

Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review

<p>Abstract</p> <p>Background</p> <p>Acute respiratory failure due to thyroid compression or invasion of the tracheal lumen is a surgical emergency requiring urgent management. The aim of this paper is to describe a series of six patients treated successfully in the emergency setting with total thyroidectomy due to ingravescent dyspnoea and asphyxia, as well as review related data reported in literature.</p> <p>Methods</p> <p>During 2005-2010, of 919 patients treated by total thyroidectomy at our Academic Hospital, 6 (0.7%; 4 females and 2 men, mean age: 68.7 years, range 42-81 years) were treated in emergency. All the emergency operations were performed for life-threatening respiratory distress. The clinical picture at admission, clinical features, type of surgery, outcomes and complications are described. Mean duration of surgery was 146 minutes (range: 53-260).</p> <p>Results</p> <p>In 3/6 (50%) a manubriotomy was necessary due to the extension of the mass into the upper mediastinum. In all cases total thyroidectomy was performed. In one case (16.7%) a parathyroid gland transplantation and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and 4 pleural effusions, treated by medical therapy in 3 and by drains in one. There was no mortality.</p> <p>Conclusion</p> <p>On the basis of our experience and of literature review, we strongly advocate elective surgery for patients with thyroid disease at the first signs of tracheal compression. When an acute airway distress appears, an emergency life-threatening total thyroidectomy is recommended in a high-volume centre.</p

Atypical Ductal Hyperplasia after Vacuum-Assisted Breast Biopsy: Can We Reduce the Upgrade to Breast Cancer to an Acceptable Rate?

(1) Background: to evaluate which factors can reduce the upgrade rate of atypical ductal hyperplasia (ADH) to in situ or invasive carcinoma in patients who underwent vacuum-assisted breast biopsy (VABB) and subsequent surgical excision. (2) Methods: 2955 VABBs were reviewed; 141 patients with a diagnosis of ADH were selected for subsequent surgical excision. The association between patients' characteristics and the upgrade rate to breast cancer was evaluated in both univariate and multivariate analyses. (3) Results: the upgrade rates to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) were, respectively, 29.1% and 7.8%. The pooled upgrade rate to DCIS or IC was statistically lower at univariate analysis, considering the following parameters: complete removal of the lesion (p-value &lt; 0.001); BIRADS ≤ 4a (p-value &lt; 0.001); size of the lesion ≤15 mm (p-value: 0.002); age of the patients &lt;50 years (p-value: 0.035). (4) Conclusions: the overall upgrade rate of ADH to DCIS or IC is high and, as already known, surgery should be recommended. However, ADH cases should always be discussed in multidisciplinary meetings: some parameters appear to be related to a lower upgrade rate. Patients presenting these parameters could be strictly followed up to avoid overtreatment

Strategies for Breast Cancer Surgery During & After COVID-19 Pandemic

Background: In December 2019, a severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), also named "COVID-19", has produced a global pandemic and has seriously affected many health systems around the world. Since the World Health Organization (WHO) declared the novel COVID-19 outbreak as a global pandemic, many international societies and groups of experts have published clinical guidelines and recommendations for surgical management of breast cancer patients in this time of crisis and issued COVID guidelines to prioritize surgery where time is critical and it cannot be deferred.Methods: In this study, we review current recommendations for breast cancer surgery during the COVID-19 pandemic and propose a plan for future waves of the current pandemic while minimizing the risk of the contagious disease and oversaturating the health systems regarding the burden of accumulating untreated disease.Results: We create a critical and constructive vision from learnt lessons for similar future situations and propose a moving forward plan during and after the COVID-19 pandemic. Conclusion: Although in many parts of world, it would appear that now we are past the peak of the COVID-19 pandemic, we still face as uncertainty as to the future course of the pandemic and the challenges of the second wave. It is important to reappraise continuously the guidance and to emphasize the need for new protocols under new norms to continue to deliver breast cancer surgery safely

immediate breast reconstruction after mastectomy

Summary Aims There is a general agreement for immediate breast reconstruction in case of in situ tumors, while the reconstruction is often still delayed in cases of invasive cancers or not performed in the elderly cohort. Aim of this review is to investigate the safety of immediate postmastectomy reconstruction for invasive cancers and in the elderly population. Methods and results We reviewed our series and the recent literature on this topic. While there is a general consensus that advanced age is not a contraindication to immediate reconstruction and breast reconstruction can be successfully performed on well-selected elderly patients, many oncologists in Europe do not prefer immediate reconstruction for invasive carcinoma, advocating the risk of delay of the medical adjuvant treatment in case of complications due to the reconstructive procedure. Our experience and a lot of studies suggest that immediate breast reconstruction is a safe and reliable treatment option in case of invasive cancers. However, if postmastectomy irradiation is necessary on the basis of the final pathological finding, this is associated with a high rate of surgical complications and implant loss among patients who underwent immediate reconstruction with prostheses. Moreover, current evidence suggests that postmastectomy radiation therapy also adversely affects autologous tissue reconstruction. Conclusions Immediate breast reconstruction after mastectomy is an integral part of the complete management of breast cancer. Determining the risk of postmastectomy irradiation prior to definitive resection and reconstructive operations may reduce complications and improve aesthetic outcomes by guiding surgical decision making

Bowel Obstruction Caused by Primitive Fibromuscular Hyperplasia of the Seminal Vesicle in the Elderly

A 79-year-old man with a 1-day history of increasing abdominal pain, decreased bowel activity, and abdominal distension was evaluated in emergency. Transabdominal pelvic ultrasonography and computerized tomography scans of the abdomen and pelvis showed the presence of a large pelvic multiloculated cystic mass between the bladder and rectum. At laparotomy, an extraperitoneal cystic lesion that was 20 cm in diameter was found to be compressing the bladder anteriorly and the rectum posteriorly. Definitive pathological diagnosis was fibromuscular hyperplasia of the seminal vesicle. The etiology of the cyst was most likely congenital, because a postoperative vesiculo-deferentography excluded the diagnosis of seminal stones. Prostatic disease was also excluded by a transrectal ultrasonograph. The patient's recovery was uneventful, and he was discharged on the seventh postoperative day. This is the first bowel obstruction caused by a congenital seminal vesicle cyst in the elderly reported in the literature

Massive mesenteric ischemia resulting from a giant strangulated umbilical hernia

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