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Elevation of Parathyroid Hormone Levels in Children Who Underwent Parathyroidectomy for Hyperparathyroidism—Reply

Elevation of Parathyroid Hormone Levels in Children Who Underwent Parathyroidectomy for... In reply Elevated PTH levels in the setting of normal serum calcium levels after successful parathyroidectomy for primary hyperparathyroidism (pHPT) can be disconcerting to referring physicians and treating surgeons alike, with the etiology and clinical significance of elevated PTH levels unclear. Among other issues that remain, the significance of elevated PTH levels in younger patients, particularly children, after parathyroidectomy is not clearly understood. Šedý and colleagues described their experience of treating 10 children (≤17 years of age) with pHPT.1 In this study, children comprised 1.27% of all patients with pHPT undergoing parathyroidectomy between 1996 and 2007. Bilateral neck exploration was performed in all patients with one parathyroid adenoma resected. One reoperation was necessary owing to a missed ectopic parathyroid adenoma. Postoperative PTH levels, however, were not presented or discussed in their article. According to Šedý, 7 of 10 children had normal PTH levels in the postoperative and follow-up period of only 3 days. In our study, 3 of 505 patients (0.6%) were aged 17 years or younger and had a postoperative follow-up of at least 6 months.2 These patients had mean preoperative calcium and PTH levels of 13.1 mg/dL and 173 pg/mL, respectively. All patients had a single adenoma removed using focused parathyroidectomy with a mean follow-up of 34 months (12-68 months) in which postoperative calcium, PTH, and creatinine levels were all normal. In our study, elevated PTH was associated with older patients, higher preoperative PTH levels, and slightly larger glands. Since only a few patients were 17 years or younger, we cannot conclude that children and adolescents are less likely to have normocalcemic PTH elevation after successful parathyroidectomy. To address the incidence and significance of elevated PTH levels in children and adolescents, a long-term study of a large pediatric population surgically treated for pHPT would be ideal. In contrast to Šedý and colleagues,1 we define operative success as eucalcemia lasting 6 months or longer. Recurrent HPT is defined as elevated calcium and PTH levels for more than 6 months after successful parathyroidectomy. Indeed, as our study demonstrates, the earliest and latest recurrences occurred at 24 and 120 months.2 Any conclusions from a small group of patients with short-term data and limited follow-up may lead to misconceptions and complacency in the treatment of these patients. Finally, the consideration of multiple endocrine neoplasia (MEN) and isolated familial HPT in younger patient populations is essential, an aspect not clearly described by Šedý and colleagues.1 Although retrospective long-term studies may allow for familial and MEN causes of HPT to be reliably excluded, such conditions can be difficult to ascertain at initial clinical presentation. When familial HPT or MEN is suspected, additional biochemical and genetic testing may be warranted for definitive diagnosis. When MEN or isolated familial HPT is not considered, younger patients may be treated with insufficient parathyroidectomy, which may result in recurrent or persistent disease in the later postoperative period. The importance of longer follow-up cannot be overemphasized in this patient population. Correspondence: Dr Solorzano, Division of Endocrine Surgery, University of Miami Miller School of Medicine, 1475 NW 12 Ave, SCC-3550, Miami, FL 33136 (csolorzano@med.miami.edu). Author Contributions:Study concept and design: Lew and Solorzano. Acquisition of data: Lew and Solorzano. Analysis and interpretation of data: Lew and Solorzano. Drafting of the manuscript: Lew. Critical revision of the manuscript for important intellectual content: Lew and Solorzano. Administrative, technical, and material support: Lew and Solorzano. Study supervision: Lew. Financial Disclosure: None reported. References 1. Libánský PAstl JAdamek S et al. Surgical treatment of primary hyperparathyroidism in children: report of 10 cases. Int J Pediatr Otorhinolaryngol 2008;72 (8) 1177- 1182PubMedGoogle ScholarCrossref 2. Solorzano CCMendez WLew JI et al. Long-term outcome of patients with elevated parathyroid hormone levels after successful parathyroidectomy for sporadic primary hyperparathyroidism. Arch Surg 2008;143 (7) 659- 663PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Elevation of Parathyroid Hormone Levels in Children Who Underwent Parathyroidectomy for Hyperparathyroidism—Reply

Archives of Surgery , Volume 144 (1) – Jan 19, 2009

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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2008.517
Publisher site
See Article on Publisher Site

Abstract

In reply Elevated PTH levels in the setting of normal serum calcium levels after successful parathyroidectomy for primary hyperparathyroidism (pHPT) can be disconcerting to referring physicians and treating surgeons alike, with the etiology and clinical significance of elevated PTH levels unclear. Among other issues that remain, the significance of elevated PTH levels in younger patients, particularly children, after parathyroidectomy is not clearly understood. Šedý and colleagues described their experience of treating 10 children (≤17 years of age) with pHPT.1 In this study, children comprised 1.27% of all patients with pHPT undergoing parathyroidectomy between 1996 and 2007. Bilateral neck exploration was performed in all patients with one parathyroid adenoma resected. One reoperation was necessary owing to a missed ectopic parathyroid adenoma. Postoperative PTH levels, however, were not presented or discussed in their article. According to Šedý, 7 of 10 children had normal PTH levels in the postoperative and follow-up period of only 3 days. In our study, 3 of 505 patients (0.6%) were aged 17 years or younger and had a postoperative follow-up of at least 6 months.2 These patients had mean preoperative calcium and PTH levels of 13.1 mg/dL and 173 pg/mL, respectively. All patients had a single adenoma removed using focused parathyroidectomy with a mean follow-up of 34 months (12-68 months) in which postoperative calcium, PTH, and creatinine levels were all normal. In our study, elevated PTH was associated with older patients, higher preoperative PTH levels, and slightly larger glands. Since only a few patients were 17 years or younger, we cannot conclude that children and adolescents are less likely to have normocalcemic PTH elevation after successful parathyroidectomy. To address the incidence and significance of elevated PTH levels in children and adolescents, a long-term study of a large pediatric population surgically treated for pHPT would be ideal. In contrast to Šedý and colleagues,1 we define operative success as eucalcemia lasting 6 months or longer. Recurrent HPT is defined as elevated calcium and PTH levels for more than 6 months after successful parathyroidectomy. Indeed, as our study demonstrates, the earliest and latest recurrences occurred at 24 and 120 months.2 Any conclusions from a small group of patients with short-term data and limited follow-up may lead to misconceptions and complacency in the treatment of these patients. Finally, the consideration of multiple endocrine neoplasia (MEN) and isolated familial HPT in younger patient populations is essential, an aspect not clearly described by Šedý and colleagues.1 Although retrospective long-term studies may allow for familial and MEN causes of HPT to be reliably excluded, such conditions can be difficult to ascertain at initial clinical presentation. When familial HPT or MEN is suspected, additional biochemical and genetic testing may be warranted for definitive diagnosis. When MEN or isolated familial HPT is not considered, younger patients may be treated with insufficient parathyroidectomy, which may result in recurrent or persistent disease in the later postoperative period. The importance of longer follow-up cannot be overemphasized in this patient population. Correspondence: Dr Solorzano, Division of Endocrine Surgery, University of Miami Miller School of Medicine, 1475 NW 12 Ave, SCC-3550, Miami, FL 33136 (csolorzano@med.miami.edu). Author Contributions:Study concept and design: Lew and Solorzano. Acquisition of data: Lew and Solorzano. Analysis and interpretation of data: Lew and Solorzano. Drafting of the manuscript: Lew. Critical revision of the manuscript for important intellectual content: Lew and Solorzano. Administrative, technical, and material support: Lew and Solorzano. Study supervision: Lew. Financial Disclosure: None reported. References 1. Libánský PAstl JAdamek S et al. Surgical treatment of primary hyperparathyroidism in children: report of 10 cases. Int J Pediatr Otorhinolaryngol 2008;72 (8) 1177- 1182PubMedGoogle ScholarCrossref 2. Solorzano CCMendez WLew JI et al. Long-term outcome of patients with elevated parathyroid hormone levels after successful parathyroidectomy for sporadic primary hyperparathyroidism. Arch Surg 2008;143 (7) 659- 663PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Jan 19, 2009

Keywords: parathyroid hormones,hyperparathyroidism,child,parathyroidectomy

References