1 / 39

APPROACH TO HYPERCALCEMIA

APPROACH TO HYPERCALCEMIA. Elizabeth George M.D. Department of Medicine University of Wisconsin-Madison. * No Financial Disclosures. WHY IS IT IMPORTANT?. Rising Incidence: 100,000 new cases / year in the United States Asymptomatic Hyperparathyroidism is not a benign condition

lelia
Télécharger la présentation

APPROACH TO HYPERCALCEMIA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. APPROACH TO HYPERCALCEMIA Elizabeth George M.D. Department of Medicine University of Wisconsin-Madison * No Financial Disclosures

  2. WHY IS IT IMPORTANT? • Rising Incidence: 100,000 new cases / year in the United States • Asymptomatic Hyperparathyroidism is not a benign condition • Skeletal loss1 • Impaired renal function • May herald underlying occult malignancy2 / sarcoidosis

  3. LEARNING OBJECTIVES • To be able to interpret an abnormal calcium and diagnose its cause • Review key elements of diagnostic evaluation • Review indications for medical monitoring vs. surgical treatment 4,5 in patients with asymptomatic hyperparathyroidism

  4. LEARNING OBJECTIVES (cont.) • Review medical therapy • Review surgical treatment • Role of gland localization techniques • Merits of minimally invasive parathyroid surgery

  5. CASE REPORT - 1 • Ms. K is a 51 year old patient who came in for a routine exam • Past medical history • Menorrhagia • Carpal tunnel syndrome • Medications – MVI • Social / Family History - unremarkable • Review of systems • Mild depression – attributed to increased stress at work • Fatigue • Difficulty concentrating

  6. CASE REPORT - 1 • Physical exam – completely unremarkable • Laboratory Data: • CBC - normal • TSH - 2.06 (0.5 – 4.00) • BMP – normal except calcium 12.4 mg/dl (8.4 – 10.4 mg/dl) • Further work up • iPTH – 509 (12-72 pg/ml) • 24 hr urine calcium – 649.3 (50 – 400 mg/24 hr) • 1,25 dihydroxyvitamin D3 - 75 (22 – 67 ng/ml)

  7. CASE REPORT - 1 Parathyroid scan (sestamibi) – negative

  8. CASE REPORT - 1 Subtraction scan

  9. CASE REPORT - 1 Subtraction scan

  10. CASE REPORT - 1 Left upper lobe parathyroid adenoma

  11. CASE REPORT - 1 Rx • Minimally invasive parathyroidectomy • Yielded an 880 mg parathyroid adenoma

  12. CASE REPORT - 2 • Ms. C is a 67 year old patient who came in for a routine exam • Past medical history • HTN • TAH with BSO 20+ years ago • Hyperlipidemia • Medications • Propanalol • Triamterene / HCTZ • Lipitor • MVI • Calcium

  13. CASE REPORT - 2 • Social / Family History – nonsmoker, completely unremarkable family history • ROS – negative • Physical exam - normal • Screening • Mammogram – recent normal • Colonoscopy – current normal except hemorrhoids • Bone density scan (DEXA) ordered

  14. CASE REPORT - 2 • Results of bone density scan t-score – 1.3 (spine) – 2. 8 (femur) • Metabolic evaluation for low bone density pursued

  15. CASE REPORT - 2 • Calcium – 11. 5 (8.4 – 10.4 mg/dl) • Ionized calcium – 6.2 (4.6 – 5.4) • iPTH 41 (10 – 65.0 pg/ml) • 24 hr urine calcium – 129.5 (100 – 300 mg/24 hr) • 1,25 dihydroxy vitamin D – 38 (15 – 60 ng/ml)

  16. CASE REPORT - 2 Chest X-ray • multiple lung nodules

  17. CASE REPORT - 2 Chest X-ray • multiple lung nodules

  18. CASE REPORT - 2 CT scan chest • large 4.3 cm nodule R lung • multiple nodules • no adenopathy

  19. CASE REPORT - 2 CT scan chest • large 4.3 cm nodule R lung • multiple nodules • no adenopathy

  20. CASE REPORT – 2 • CT abdomen and pelvis – negative • Biopsy of lung mass • Well differentiated, low grade neuroendocrine carcinoma (carcinoid)

  21. WORK-UP OF HYPERCALCEMIA IN AN ASYMPTOMATIC PATIENT Re-review History • Classic presentation very rare • Stones • Bones • Abdominal groans • Psychic moans • Subtle manifestations more common • Fatigue • Weakness • Arthralgias

  22. WORK-UP (cont.) • History • Non specific GI complaints • Depression • Impairment of intellectual performance • Associated conditions • Pseudogout • Nephrolithiasis

  23. WORK-UP (cont.) • Review medications • Thiazides • Theophylline • Lithium • Antacids • Food additives • Health food store preparations • Pursue symptoms of underlying malignancy • Breast • Lung • Hematological • Past History of Neck irradiation3

  24. WORK-UP (cont.) • Physical exam • Generally unrevealing • Band keratopathy with slit lamp • Breast mass • Adenopathy • Bone tenderness

  25. WORK-UP (cont.) • Step 1 • Confirm hypercalcemia • Ionized calcium • Serum albumin levels • Artifactual – tourniquet • Step 2 • Once obvious causes ruled out, obtain serum intact PTH

  26. WORK-UP (cont.) • Serum Parathyroid Hormone levels - ELEVATED • Primary hyperparathyroidism – 75-80% (sporadic) • Familial (MENI and MENII) • Familial hypocalciuric hypercalcemia • Ectopic PTH secretion by tumors (rare)

  27. WORK-UP (cont.) • Normal / Low • Malignancy associated • Osteolytic • Humoral • Vitamin D mediated • Intoxication • Granulomatous disorders • Thyrotoxicosis • Prolonged immobilization • Pagets • Acute renal failure • Milk alkali syndrome

  28. MEDICAL vs. SURGICAL Rx FOR ASYMPTOMATIC HYPERPARATHYROIDISM Indications for medical monitoring • Mildly elevated calcium • No previous episodes of life threatening hypercalcemia • Normal renal function • Normal bone status

  29. INDICATIONS FOR SURGICAL TREATMENT (J. Clin Endocrinology Metab, Dec. 2002, 87(12): 5353-5361) • Overt clinical manifestations • Serum calcium > 1mg/dl above upper limits of normal • 24 hr urine calcium > 400mg • Bone density < 2.5 SD below peak bone mass (t score < -2.5) • Age < 50 years • Medical surveillance not desirable / not possible

  30. MEDICAL THERAPY Monitoring • Blood pressure • Biannual serum calcium • Annual serum creatinine • Annual bone density • Baseline abdominal radiographs for silent stones

  31. MEDICAL MANAGEMENT • Avoid prolonged immobilization • Maintain adequate hydration • Avoid a diet with restricted or excess calcium • Caution with loop/thiazide diuretics • Estrogen therapy – limited data • Bisphosphonates, calcitonin only in symptomatic patients who are non surgical candidates

  32. SURGICAL THERAPY Role of gland localization • Pre-op localization mandatory when Minimally Invasive Parathyroidectomy (MIP) procedure planned • Procedure used – 99Tc labeled sestamibi scan

  33. SURGICAL THERAPY (cont.) Minimally Invasive Parathyroidectomy (MIP) • Pre-op localization • Intra-op PTH level obtained before and after adenoma removed • If PTH levels fall by greater than 50% operation terminated • IF PTH Levels fall by less than 50%, full neck exploration performed

  34. SURGICAL THERAPY (cont.) Conventional • Full exploration of neck • Rationale -15-20% patients have > 1 gland removed • Requires highly skilled surgeon • Complications- rate 1-4% • Vocal cord paralysis • Permanent hypoparathyroidism • Bleeding • Laryngospasm

  35. POST OPERATIVE MONITORING • Watch for symptomatic hypocalcemia • Provide oral calcium and 1,25 (OH)2 D3, once oral intake established • Check serum calcium at intervals of several days

  36. MANAGEMENT OF HYPERCALCEMIA OF MALIGNANCY • Vigorous rehydration / saline diuresis • Bisphosphonates • Pamidronate • Etidronate • Calcitonin • Definitive measure • Rx underlying tumor

  37. SUMMARY OF WORKUP FOR HYPERCALCEMIA

  38. SUMMARY OF WORKUP FOR HYPERCALCEMIA

  39. References • Khosla S. et al., Primary hyperparathyroidism and the risk of fracture” A population based study, J. Bone Miner Res, 1999; 14: 1700-1707. • Ralston SH, et al., Cancer associated hypercalcemia: Morbidity and mortality. Ann Intern Med, 1990; 112: 499-504. • Schneider AB, Gierlowski TC, Shore-Freedman et al., Dose response relationships for radiation induced hyperparathyroidism, J Clin Endo Metab, 1995; 80: 254-257. • Potts JT Jr (editor), Proceedings of the NIH consensus development conference on diagnosis and management of asymptomatic primary hyperparathyroidism, J. Bone Miner Res, 1991; 6 (suppl) s9-s13. • J Clin Endo Metab, 2002; 87 (12); 5353-5361.

More Related